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THE 
CASE  HISTORY  SERIES 


CASE    HISTORIES    IN    MEDICINE 

BY 

Richard  C.  Cabot,  M.D. 

Second  edition,  revised  and  enlarged 


CASE    HISTORIES    IN    PEDIATRICS 

BY 

John  Lovett  Morse,  M.D. 


ONE   HUNDRED    SURGICAL   PROBLEMS 

BY 

James  G.  Mumford,  M.D. 


CASE    HISTORIES    IN   NEUROLOGY 

BY 

E.  W.  Taylor,  M.D. 


CASE   HISTORIES 


IN 


NEUROLOGY 

A    SELECTION    OF    HISTORIES    SETTING    FORTH    THE 

DIAGNOSIS,    TREATMENT   AND    POST-MORTEM 

FINDINGS   IN    NERVOUS   DISEASE 


BY 

E.  W.  TAYLOR,  A.M..  M.D. 

Instructor  in  Neurology,  Harvard  Medical  School;    Assistant  Physician,  Department  of 

Neurology,  Massachusetts  General  Hospital;  Visiting  Neurologist, 

Long  Island  Hospital,  Boston 


BOSTON 

W.  M.  LEONARD,  Publisher 
19n 


Copyright^  iqit, 
By   IV.  M.  Leonard. 


PREFACE. 

The  object  of  this  book  is  to  set  forth  in  practical  form,  on  the 
basis  of  the  Case  System,  certain  fundamental  facts  regarding  the 
symptomatology,  diagnosis,  treatment  and  pathological  findings 
in  the  more  frequent  disorders  of  the  nervous  system.  To  accom- 
plish this  end,  actual  cases  illustrating  definite  disease  processes  or 
predominating  symptoms  are  narrated  in  some  detail,  followed  by 
such  explanatory  remarks  as  the  individual  case  demands.  Atten- 
tion has  also  been  given  to  the  important  matter  of  differential 
diagnosis.  The  arrangement  of  the  cases  has  followed  the  time- 
honored  and  useful  if  somewhat  inaccurate  anatomical  method  of 
division  into,  (i)  peripheral,  (2)  spinal  cord  and  (3)  brain  diseases, 
followed  by  (4)  those  for  which  a  definite  anatomical  basis  has  not 
yet  been  found,  and  (5)  by  affections  characterized  by  disorders  of 
function,  the  neuroses.  Very  brief  explanatory  sections  on  principles 
of  diagnosis  and  treatment  precede  and  follow  the  main  divisions  of 
the  subject  matter,  which  in  no  way  interferes  with  the  primary 
object  of  presenting  to  the  reader  case  histories  on  the  principle 
developed  for  medicine  by  Prof.  W.  B.  Cannon  and  later  put  into 
practical  operation  by  many  teachers  in  Boston  and  elsewhere.  I 
am  indebted  to  Miss  Florence  L.  Spaulding  for  assistance  in  the 
illustration  of  the  book. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/casehistoriesinnOOtayl 


TABLE  OF  CONTENTS. 

Introduction.  Page. 

General  Statement  of  Diagnostic  Methods 1 1 

Motion  —  Sensation  —  Mind. 
Types  of  Paralysis. 

Section  I.     Peripheral  Nerves. 

Case    I.  Alcoholic  Neuritis 23 

2.  Alcoholic  Neuritis  —  Pseudo-tabes 25 

3.  Arsenical  Neuritis 27 

4.  General  Neuritis 29 

5.  Lead  Neuritis      31 

6.  Syphilitic  Neuritis 33 

7.  Brachial  Neuritis 35 

8.  Brachial  Neuritis 37 

9.  Sciatica  —  Pressure 38 

10.  Sciatica  —  Tumor 39 

11.  Sciatica  —  Ordinary  Type 41 

12.  Sciatica  —  Sacro-iliac 42 

13.  Brachial  Plexus  Injury 43 

14.  Obstetrical  Paralysis 45 

15.  Subdeltoid  Bursitis 46 

16.  Musculospiral  Injury 48 

17.  Median  Neuritis 51 

18.  Ulnar  Neuritis 53 

19.  Peroneal  Injury 55 

20.  Facial  Paralysis 56 

21.  Facial  Paralysis — Injury 58 

22.  Facial  Paralysis  — •  Involvement  of  Taste 60 

Section  II,    Spinal  Cord. 

Case  23.  Poliomyelitis 64 

24.  Poliomyelitis  —  Meningeal  Type 67 

25.  Poliomyelitis  —  Cranial  Nerve  Involvement 69 

26.  Poliomyelitis  —  Paralysis  of  Respiration 72 

27.  Poliomyelitis  —  Landry  Type      74 

28.  Progressive  Muscular  Atrophy  —  Spinal  Type 77 

29.  Progressive  Muscular  Atrophy  —  Family  Type 79 

30.  Progressive  Muscular  Atrophy — Peroneal  Type 81 

31.  Progressive  Muscular  Dystrophy 83 

32.  Amyotrophic  Lateral  Sclerosis 85 

33.  Tabes 88 

5 


6  TABLE    OF   CONTENTS. 

Page. 

Case  34.  Tabes 90 

35.  Tabes 92 

36.  Tabes  —  Retained  Deep  Reflexes 93 

37.  Tabes  —  Optic  Atrophy 95 

38.  Tabes — Mental  Symptoms 96 

39.  Ataxic  Paraplegia 99 

40.  Ataxic  Paraplegia  —  Pernicious  Anemia 102 

41.  Myelitis  —  Transverse  Thoracic      104 

42.  Myelitis — Incomplete  Lumbar 107 

43.  Injury  of  Cord  —  Fracture  of  Vertebrae 109 

44.  Injury- of  Cord  —  Contre-coup in 

45.  Injury  of  Cord  —  Bullet  Wound 113 

46.  Injury- of  Cord  —  Complete  Cervical  Crush      115 

47.  Injury- of  Cord  —  Brown-Sequard  Type 117 

48.  Injury- of  Cord  —  Subdural  Hemorrhage 120 

49.  Multiple  Sclerosis 122 

50.  Multiple  Sclerosis 124 

51.  Syringomyelia 128 

52.  Spina  Bifida 131 

53.  Syphilitic  Spinal  Paralysis 135 

54.  Pott's  Disease I37 

55.  Carcinoma  of  Spine  involving  Cord 140 

56.  Tumor  of  Cord  — •  Operation 142 

57.  Tumor  of  Cord 146 

58.  Friedreich's  Ataxia 151 

Section  III.     Brain. 

Case  59.  Dementia  Paralytica 155 

60.  Dementia  Paralytica  —  Cerebral  Attacks 158 

61.  Hemiplegia  —  Traumatic      161 

62.  Hemiplegia 163 

63.  Hemiplegia  —  Aphasia      165 

64.  Hemiplegia  —  Progressive 167 

65.  Hemiplegia  —  Puerperal 169 

66.  Hemiplegia  —  Infantile 171 

67.  Hemiplegia  —  Embolism,  Softening 173 

68.  Arteriosclerosis 176 

69.  Senile  Trepidant  Abasia 179 

70.  Aphasia  —  Transient  Hemiplegia.     Hemianopsia 181 

71.  Aphasia  —  Recovery 184 

72.  Aphasia  —  Abscess  of  Brain 186 

73.  Abscess  —  Operation 189 

74.  Sinus  Thrombosis 192 

75.  Infantile  Cerebral  Paralysis 194 

76.  Encephalitis 197 

77.  Brain  Tumor  —  Decompression 200 

78.  Brain  Tumor  —  Astereognosis 204 

79.  Brain  Tumor  —  Pons 209 

80.  Brain  Tumor  • — •  Temporal  Lobe      212 


TABLE    OF   CONTENTS.  7 

Pace. 

Case    8l.  Brain  Tumor  —  Region  of  Hypophysis      216 

82.  Hydrocephalus 220 

83.  Ophthalmoplegia 221 

84.  Progressive  Bulbar  Paralysis 223 

85.  Progressive  Bulbar  Paralysis  —  Senile 225 

86.  Acute  Bulbar  Paralysis 227 

87.  Paralysis  of  Fifth  and  Seventh  Nerves 229 

88.  Tubercular  Meningitis • 232 

89.  Syphilis  —  Brain 235 

90.  Traumatism  —  Head 237 

91.  Injury  —  Brain 240 

Section  IV.     Conditions  of  Vague  or  Undetermined  Pathological  Basis. 

Case    92.  Paralysis  Agitans      243 

93.  Chorea  Minor 246 

94.  Habit  Tic 248 

95.  Spasmodic  Torticollis 250 

96.  Exophthalmic  Goitre 252 

97.  Myxedema 254 

98.  Epilepsy 256 

99.  Epilepsy  —  Late 258 

100.   Migraine 260 

loi.  Headache  —  Eyestrain 262 

102.  Acromegaly 263 

103.  Myasthenia  Gravis 265 

104.  Acroparesthesia 267 

105.  Meniere's  Disease 269 

106.  Raynaud's  Disease 272 

107.  Trigeminal  Neuralgia 274 

108.  Herpes  Zoster 277 

109.  Occupation  Neurosis: 

(A)  Stone-cutting 279 

(B)  Massage      279 

(C)  Piano-playing 279 

(D)  Writing 280 

Section  V.     Psychoneuroses. 

Case  no.  Hypochondriasis 283 

111.  Association  Neurosis  —  Anxiety 287 

112.  Hysteria 291 

113.  Traumatic  Neurosis  —  Hysterical  Type       294 

114.  Neurosis — ■Association  Type 298 

Index 301 


CASE   HISTORIES 

IN 

NEUROLOGY. 


INTRODUCTION. 


GENERAL   STATEMENT  OF   DIAGNOSTIC 
METHODS. 

The  study  of  the  nervous  system  either  under  normal  or 
pathological  conditions  cannot  be  separated  from  that  of  other 
organs  and  structures,  with  which  it  stands  in  close  relation. 
The  relations  with  the  muscular  and  vascular  systems  are 
particularly  intimate,  and  in  general  neurology  should  be 
regarded  as  an  integral  part  of  internal  medicine,  demanding 
special  study  because  of  its  complexity  of  structure  and  func- 
tion and  the  consequent  variety  of  its  diseases.  Certain 
anatomical  and  physiological  considerations  are  essential  to 
an  understanding  of  the  symptomatology  of  nervous  disease, 
which  is  a  departure  from  the  normal,  either  on  the  side  of 
structure  —  organic  or  structural  disease  —  or  on  the  side  of 
function  —  so-called  functional  disease.* 

In  undertaking  a  systematic  elementary  study  of  disorders 
of  the  nervous  system  on  the  basis  of  actual  cases,  it  is 
desirable  briefly  to  consider  its  three  fundamental  functions : 
A.  Motion;  B.  Sensation;  C.  Mind,  from  an  anatomical 
and  physiological  standpoint. 

MOTION. 
Anatomical  and  Physiological  Considerations. 

The  path  of  voluntary  motion  originates  in  the  cerebral 
cortex,  chiefly  in  the  convolution  ventral  to  the  fissure  of 
Rolando  and  extending  from  the  fissure  of  Sylvius  to  the  vertex 
of  the  brain  (Fig.  i).  Thence  the  axones  are  concen- 
trated into  a  compact  bundle  which  passes  through  the 
ventral  portion  of  the  dorsal  limb  of  the  internal  capsule, 

*  These  are  terms  of  convenience.  A  sharp  distinction  is  not  to  be  drawn  between  structural 
and  functional  disease. 


12  CASE  HISTORIES   IN   NEUROLOGY. 

from  there  into  the  central  portion  of  the  pes  pedunculi, 
through  the  pons,  where  its  fibers  are  separated  by  the  trans- 
verse fibers  of  that  structure,  finally  emerging,  as  the  ventral 
pyramid  of  the  oblongata,  and,  after  crossing  in  its  lower 
part,  passing  into  the  spinal  cord  as  the  crossed  pyramidal 
tract. 


Cortical  Motor  Areas. 

The  pathway  is  continued  to  the  muscles  from  the  ventral 
horns  of  the  cord  (and  also  from  the  motor  cranial  nerve 
ganglia) ,  ultimately  terminating  in  the  plates  of  the  skeletal 
muscles. 

The  motor  system,  therefore,  consists  of  two  neurones, 
variously  known  as  the  corticospinal  motor  neurone,  — central 
neurone,  neurone  of  the  second  order,  and  the  spinal-periph- 
eral,—  peripheral  or  motor  neurone  of  the  first  order.  The 
connection  between  them  in  the  ventral  gray  substance  is 
through  collateral  branches  from  the  pyramidal  tracts  to  the 
dendritic  processes  of  the  cell  bodies  of  the  peripheral  neurones. 
Whatever  the  exact  anatomical  relations  may  be,  the  impor- 
tant practical  point  is  that  the  physiological  connection  be- 
tween the  central  and  peripheral  motor  neurones  is  complete, 
and  that  any  break  in  this  connection  leads  to  motor  defect. 

In  order  that  voluntary  movements  may  be  performed,  the 
integrity  of  the  entire  motor  tract,  from  center  to  periphery, 


CASE   HISTORIES   IN    NEUROLOGY. 


13 


is  essential.  If  through  disease  or  injury  the  path  of  conduc- 
tion is  interrupted  at  any  point  in  the  course  of  either  of  the 
neurones,  paralysis  (complete  loss  of  power)  or  paresis 
(partial  loss  of  power)  results.  Injury  of  either  peripheral  or 
central  motor  neurone  therefore  leads  to  paralysis. 

Peripheral  Motor  Neurone.  The  peripheral  or  spinal- 
muscular  motor  neurones  extend  from  cell-bodies  in  the 
ventral  horns  of  the  cord,  or  from  the  corresponding  nuclei 
of  the  motor 
cranial  nerves,  to 
the  various  vol- 
untary muscles. 
The  integrity  of 
the  muscles  is  de- 
pendent upon  the 
integrity  of  the 
motor  nerves. 
The  muscles  and 
the  motor  nerves 
must,  therefore, 
always  be  con- 
sidered together 
as  parts  of  a  single 
mechanism.  De- 
struction, or  seri- 
ous injury  from 
whatever  cause, 
of  the  peripheral 
motor  neurone 
leads  to  muscular 
atrophy,  and  this 
to  a  lack  of  tonic- 
ity (hypo  tonicity) 
or  to  a  flaccid  pa- 
ralysis. Associated  with  this  condition  are  alterations  of  elec- 
trical reactions.  Finally,  disease  of  peripheral  motor  neurones 
gives  rise  to  disturbances  (diminution,  loss)  of  the  so-called 
deep  or  tendon  reflexes,  among  which  the  knee  jerk  may  be 
taken  as  the  most  practically  important. 


Motor  Tracts. 


14  CASE   HISTORIES   IN   NEUROLOGY. 

Mechanism  of  the  Knee  Jerk.  (Whether  the  knee  jerk  and 
alHed  phenomena  are  true  reflexes,  or  dependent  simply 
upon  muscular  tonicity,  or  what  the  exact  physiological 
mechanism  of  the  human  reflexes  may  be,  are  matters  un- 
essential to.  an  understanding  of  clinical  conditions.) 

For  the  carrying  out  of  a  reflex  (knee  jerk)  an  intact  reflex 
arc  is  essential.  This  consists  of  a  sensory  pathway,  and  a 
motor  pathway,  connected  in  the  central  organ  (gray  matter 
of  cord).    An  interruption  of  the  arc  in  any  part  of  its  course 

(Fig.  3,  xxxx)  will 
abolish  the  reflex. 
Hence  disease  of 
the  peripheral 
motor  neurones, 
including  the  re- 

FiG.  3.     Reflex  Arc.  _, 

flex  arc  of  the 
knee  jerk,  abolishes  that  reflex.  A  similar  result  naturally 
follows  disease  of  the  sensory  neurones  essential  to  the  reflex 
(tabes  dorsalis)  and  also  disease  of  both  sensory  and  motor 
neurones  in  the  nerve  trunk   (peripheral  neuritis). 

When,  on  the  other  hand,  the  regulatory  mechanism  from 
the  brain  to  the  lower  reflex  arc  is  interfered  with  —  degenera- 
tion of  the  pyramidal  tracts,  or  corticospinal  motor  neurones 
—  the  reflexes  are  Increased,  presumably  through  cutting  ofif 
of  Inhibitory  Influences. 

Electrical  Changes.  Under  normal  conditions  nerves  and 
muscles  may  be  stimulated  to  contraction  by  both  the  faradic 
(interrupted)  and  galvanic  (constant)  currents.  The  re- 
sponses are  quick.  Under  pathological  conditions  —  degen- 
eration of  the  peripheral  motor  neurone  to  the  muscle  —  the 
contractions  are  altered  both  In  quantity  and  quality.  If 
merely  a  stronger  current  Is  required  than  usual,  the  change  is 
spoken  of  as  quantitative;  if  the  character  of  the  contraction 
Is  changed  and  the  reaction  to  the  two  poles  of  the  galvanic 
current  Is  altered,  the  condition  Is  spoken  of  as  qualitative, 
or  Reaction  of  Degeneration  (R.  D.). 

Normally,  (i)  stimulation  of  a  ner\'e  trunk  by  a  faradic 
current  (Indirect  stimulation)  produces  a  quick  contraction 
of  the  muscle  or  group  of  muscles  supplied  by  that  nerve. 


CASE   HISTORIES   IN   NEUROLOGY.  I5 

The  point  of  best  stimulation  is  known  as  a  motor  point. 
(2)  Stimulation  of  a  muscle  itself  (direct  stimulation)  pro- 
duces a  quick  contraction.  The  poles  of  the  faradic  current 
need  not  be  distinguished. 

Stimulation  of  a  nerve  by  the  galvanic  current  produces  a 
quick  contraction.  Stimulation  of  a  muscle  likewise  produces 
a  quick  contraction.  This  contraction  is  more  easily  produced 
when  the  negative  (cathode)  pole  is  used  for  stimulation. 

The  normal  formula  may  be  expressed  as  follows: 

F      d'  m       \  Nerve  — quick  contraction. 
I  Muscle  —  quick  contraction. 

Nerve  — quick  contraction. 
Galvanism     )  Muscle  —  quick  contraction. 

With  CaC  (negative  closing  contraction)  greater 
than  (>)  AnC  (positive  closing  contraction). 

Under  pathological  conditions  neither  stimulation  of  the 
nerve  nor  of  the  muscle  by  the  faradic  current  produces  a 
contraction.  Galvanic  stimulation  of  the  nerve  also  produces 
no  muscular  contraction  (conductivity  of  the  nerve  lost),  but 
applied  to  the  muscle  produces  often  an  exaggerated  but  a 
changed  response.  The  contraction  is  slow^  wavelike,  and 
the  positive  pole  has  as  great  as,  or  greater  stimulating  effect 
than  the  negative  pole. 

The  pathological  formula  (R.  D.)  may  be  expressed  as 
follows : 

Faradism       j  ^/rve  -  no  response. 
(  Muscle  —  no  response. 

Nerve  —  no  response. 

Muscle  —  active     response     with     qualitative 
Galvanism     (      changes. 

Slow   contraction,    AnC,    equal    to   or   greater 
than  (>)  CaC. 

There  are  various  stages  between  the  normal  and  complete 
R.  D.,  known  as  partial  R.  D. 

Disease  of  the  peripheral  motor  neurone,  therefore,  gives 
rise  to  the  following  objective  conditions:  i.  Paralysis. 
2.  Muscular  atrophy.  3.  Flaccidity  with  hypotonicity.  4. 
Lost  deep  reflexes.  5.  Electrical  alterations  {R.D.).  Flaccid, 
Atrophic  Paralysis. 


1 6  CASE   HISTORIES   IN   NEUROLOGY. 

Central  Motor  Neurone.  Disease  or  injury  of  the 
central  or  corticospinal  motor  neurone,  except  for  the  com- 
mon element  of  weakness  (paralysis),  differs  widely  in  its 
clinical  manifestations  from  that  of  the  peripheral  motor 
neurone  just  considered.  Inasmuch  as  it  has  no  direct 
connection  with  the  muscular  system,  injury  or  disease 
does  not  produce  muscular  atrophy  and  electrical  alterations; 
the  muscular  system  instead  of  being  hypotonic  is  hyperto?iic, 
and,  finally,  the  deep  reflexes  are  exaggerated  instead  of 
diminished.  The  hypertonicity  and  exaggerated  reflexes, 
e.  g.,  knee  jerk,  are  due  to  the  loss  of  the  controlling  influence 
of  the  brain,  through  the  degeneration  of  the  motor  pyrami- 
dal tracts.  Since  the  lower  reflex  arc  is  unaffected,  and  the 
regulatory,  inhibitive  influences  of  the  brain  are  removed, 
the  reflex  oxeracts  and  an  increased  knee  jerk  results.  Marked 
exaggeration  of  the  knee  jerk  points  to  disease  of  the  central 
motor  tracts. 

Disease  of  the  central  motor  neurone,  therefore,  gives  rise 
to  the  following  conditions :  i.  Paralysis.  2.  Spasticity  with 
hypertonicity.  3.  Exaggerated  deep  reflexes.  And  negatively: 
4.  No  muscular  atrophy.  5.  No  electrical  alterations.  Spastic, 
NoN- Atrophic  Paralysis. 

Disease  of  the  two  motor  neurones  may  be  graphically 
represented  as  follows : 

Peripheral  Neurone. 
Muscular  atrophy       j 

Hypotonicity  f  pi^^ciditv 

Diminished  reflexes    (  ^ 

Electrical  alterations  j    . 

Central  Neurone.  ,  /  Paralysis 

Increased  reflexes 

Hypertonicity  \  Spasticity 

No  atrophy 
No  electrical  alterations 

Disease  of  the  motor  neurone  system  may,  therefore, 
manifest  itself  either  as  a  flaccid,  atrophic  paralysis  (pro- 
gressive muscular  atrophy),  or  as  a  spastic  paralysis  (spastic 
paraplegia) ,  or  as  a  combination  of  the  two  types  (amyotrophic 
lateral  sclerosis).    See  later  discussion. 


CASE   HISTORIES    IN    NEUROLOGY. 


17 


SENSATION. 

Anatomical  and  Physiological  Considerations. 

The  path  of  common  sensibility  from  the  periphery  to  the 
brain  lies  in  the  sensory  portion  of  the  mixed  nerves,  or  in 
the  nerves  of  special  sense,  and  reaches  thereby  the  cord  or 
brain  stem,  passing  finally  to  the  higher  levels  of  perception 
in  the  brain  cortex.  Anatomically  the  sensory  system  consists 
of  at  least  three  superimposed  neurones,  the  lower  or  periph- 
eral of  which  is  alone  of  special  practical  diagnostic  im- 
portance. The  sen- 
sory tracts  cross  in 
the  central  system, 
in  part  in  the  cord 
and  in  part  in  the  temperature 
oblongata.  The 
general  course  of  the 
main  sensory  fibers 
in  the  cord  is  repre- 
sented in  the  accom- 
panying diagram 
(Fig.  4).  It  is  probable  that  those  fibers  which  subserve  the 
senses  of  pain  and  temperature  cross  soon  after  entering  the 
cord,  whereas  those  which  subserve  the  sense  of  contact  and 
position  pass  up  mainly  in  the  long  dorsal  tracts  (columns  of 
Burdach  and  Goll). 


EQUILIBRIUM 

T 

DIRECTCEREBELLAR  TRACT 


. CONTACT 

-  EQUILIBRIUM 

-PAIN  —»  TEMPERATURE 


Fig.  4.    Course  of  Main  Sensory  Neurones. 


Peripheral  Sensory  Neurones. 

The  integrity  of  this  system  of  neurones  is  essential  to  the 
preservation  of  normal  sensibility.  Disease  or  injury  of  these 
neurones,  therefore,  causes  various  disorders  of  sensory  per- 
ception in  the  skin  areas  supplied.  The  more  frequent  of 
these  disorders  are,  analgesia  —  loss  of  pain  sense;  anesthesia 
—  general  loss  of  sensibility;  hyperesthesia  —  increased  sen- 
sibility; paresthesia  —  unusual  sensations,  e.  g.,  prickling, 
formication,  burning,  etc. 

Disturbance  of  co-ordination  depends  upon  the  sense  of  posi- 
tion, which,  in  turn.  Is  dependent  upon  the  joint  sensation 
subserved  by  the  peripheral  sensory  neurones. 


l8  CASE   HISTORIES   IN   NEUROLOGY. 

Disturbed  sensation  is  of  much  value  in  determining 
pathological  processes,  localized  in  the  brain,  certain  seg- 
ments of  the  spinal  cord  or  in  the  periphery.  The  trophic 
functions  of  the  skin  also  frequently  suffer.  Inasmuch  also  as 
the  superficial  reflex  arc  is  partially  constituted  by  the  sensory 
neurones,  it  follows  that  a  destruction  of  these  neurones  leads 
to  an  abolition  of  the  deep  reflexes  (knee  jerk)  for  the  same 
reason  that  a  destruction  of  the  motor  peripheral  neurones 
leads  to  their  abolition.  Disease  of  the  peripheral  sensory 
neurone,  therefore,  gives  rise  to  the  following  conditions: 
I.  Disturbed  sensibility.  2.  Lost  deep  reflexes.  3.  Trophic 
disorders. 

Disease  of  the  upper  sensory  neurones  is  of  less  significance 
from  the  diagnostic  standpoint. 

The  important  areas  of  the  spinal  cord  from  a  clinical 
standpoint  are  those  tracts  of  fibers  which  are  made  up  by 
motor  neurones  of  the  peripheral  and  central  type,  and  by 
sensory  neurones  of  the  peripheral  type.  Diseases  of  these 
regions  alone  or  in  combination  give  rise  to  the  varied  signs 
and  symptoms  met  with  in  organic  disease  of  the  spinal  cord. 

From  the  accompanying  diagram  (Fig.  5),  having  in  mind 
the  functions  of  the  two  motor  tracts  and  of  the  peripheral 


SENSAHON -ATAXIA 
ATAXIC    PARAPLEGIA 


TABES  DORSALIS 


AMYOTROPHIC  LAT  SCLEROSIS 


Fig.  5.     Diagram  Illustrating  Cord  Functions  and  Disease  Processes. 

sensory  tract,  it  is  evident  that  the  diagnosis  of  many 
affections  may  be  understood  which  may  be  summarized 
as  follows: 

If  the  peripheral  motor  neurone  is  affected,  either  through 
primary  disease  of  the  neurones,  —  progressive  muscular 
atrophy,  —  or  through  destruction  of  the  nerve  cell  bodies 
lying    in    the   ventral    horns,  —  anterior    poliomyelitis,  —  a 


CASE  HISTORIES    IN   NEUROLOGY.  I9 

flaccid,  atrophic  paralysis  results,  with  electrical  changes  and 
diminished  deep  reflexes,  but  without  sensory  disorders. 

If  the  central  motor  neurone  is  involved,  a  spastic,  non- 
atrophic  paralysis  results,  with  exaggerated  deep  reflexes, 
also  without  sensory  disorders,  —  spastic  paralysis. 

If  the  sensory  peripheral  neurones  are  involved,  a  condi- 
tion of  disturbed  sensibility  results,  with  incoordination  and 
loss  of  deep  reflexes  (ataxia,  tabes  dorsalis),  but  without 
motor  weakness. 

If  the  peripheral  and  central  motor  neurones  are  both  in- 
volved, a  spastic,  atrophic  paralysis  results,  certain  groups 
of  muscles,  usually  in  the  upper  part  of  the  body,  being 
atrophic  with  lost  deep  reflexes,  and  other  groups  —  legs  — 
being  spastic  with  increased  deep  reflexes  (amyotrophic 
lateral  sclerosis). 

If  the  peripheral  sensory  neurones  and  the  central  motor 
neurones  are  together  involved,  sensory  disorders  with  ataxia 
are  combined  with  spastic  conditions,  giving  rise  to  the  symp- 
tom-complex of  ataxic  paraplegia. 

Finally,  if  the  mixed  nerve  is  involved  in  its  peripheral 
distribution,  an  atrophic  paralysis  with  sensory  symptoms 
will  result,  as  a  consequence  of  a  combined  lesion  of  the 
peripheral  motor  and  peripheral  sensory  neurones,  with  loss 
of  deep  reflexes,  in  this  case  the  reflex  arc  being  doubly 
interrupted  (peripheral  neuritis). 

The  foregoing  disturbances  are  best  studied  in  the  spinal 
cord,  but  the  same  principles  apply  to  various  lesions  of  the 
brain  stem,  implicating  cranial  nerves  (bulbar  paralysis, 
ophthalmoplegia) . 

In  all  these  affections,  in  which  the  lesions  are  so  combined 
that  one  process,  e.  g.,  degeneration  of  the  sensory  tracts  or 
the  peripheral  motor  neurones,  would  tend  to  destroy  the 
deep  reflexes  (knee  jerk),  and  the  other,  e.  g.,  degeneration  of 
the  central  motor  neurone  (pyramidal  tracts),  would  tend  to 
increase  the  deep  reflexes,  the  resultant  condition  will  depend 
upon  the  relative  extent  of  the  antagonistic  processes.  A 
knee  jerk,  for  example,  may  be  increased  early  in  the  course 
of  an  ataxic  paraplegia,  and  later  lost,  as  the  reflex  arc  itself 
becomes  involved. 


20 


CASE    HISTORIES    IN    NEUROLOGY. 


MIND. 

Study  of  the  function  of  mind  is  the  primary  work  of 
psychiatry.  It  has,  however,  become  increasingly  apparent 
that  many  of  the  neuroses  are  more  profitably  approached 
from  the  mental  side.  Hence  neurological  diagnosis  demands 
a  clear  recognition  of  the  influence  and  broad  significance 
of  mental  states  in  the  etiology  and  treatment  of  certain  fre- 
quent forms  of  nervous  disease.  The  practical  application  of 
this  knowledge  is  indicated  in  the  case  histories  (Section  V). 


TYPES  OF  PARALYSIS. 

Owing  to  the  anatomical  relations  of  the  motor  tracts,  both 
central  and  peripheral,  the  position  of  a  lesion  is  indicated 
by  certain  somewhat  definite  types  of  paralysis.  Of  these 
the  more  important  are  as  follows: 

Monoplegia  —  paralysis  of  a  single  extremity  —  is  caused 
by  a  destructive   lesion   of   the   cerebral   cortex,  because  of 

the  wide  distribution  of  motor 
function  on  the  surface  of  the 
brain.  A  lesion  sufficiently 
extensive  to  produce  a  cortical 
hemiplegia  in  an  adult  would 
in  most  instances  be  destruc- 
tive of  life.  Exceptions  to  the 
general  rule  may  occur,  as  in 
young  children  or  in  a  gradu- 
ally increasing  hemorrhage 
from  a  meningeal  artery. 

Hemiplegia  —  paralysis  of 
one  side  of  the  body,  including 
the  face — is  caused  by  a  lesion 
in  or  about  the  internal  cap- 
sule which  destroys  the  motor 
fibers  in  their  passage  downward.  The  fibers  converge  at  the 
capsule ;  hence  a  small  lesion  is  capable  of  producing  an  ex- 
tensive defect.  The  opposite  side  of  the  body  alone  is  in- 
volved, since  the  tracts  for  the  two  sides  are  still  widely 
separated. 


CROSSED   PARALYSIS 


PARAPLEGIA( 


Fig.  6.     Types  of  Paralysis. 


CASE  HISTORIES   IN   NEUROLOGY. 


21 


Crossed  Paralysis.  Lesions  of  the  crura  and  pons  may  lie 
in  such  a  position  that  the  fibers  of  one  of  the  cranial  nerves, 
third,  sixth  or  seventh,  are  invaded  after  they  have  crossed, 
whereas  the  fibers  of  the  pyramidal  tract  are  interrupted 
before  they  have  crossed,  with  the  result  that  the  muscles  of 
the  eye  or  face  are  paralyzed  on  the  same  side  as  the  lesion, 
and  the  arm  and  leg  on  the  opposite  side. 

Paraplegia  —  paralysis  of  both  sides  of  the  body  — 
points  toward  a  lesion  of  the  cord.  Since  the  size  of  the  cord 
is  such  that  the  two  motor  tracts  lie  close  together,  a  lesion 
of  sufficient  intensity  to  destroy  one  tract  is  liable  to  destroy 
both. 


Fig.  7.  Segmentai,  Distribution.  Fig.  S. 

Segmental   Paralysis.      If   the  lesion   be   in    the   ventral 
horns  of  the  cord  or  between  the  cord  and  the  plexuses,  cer- 


22  CASE   HISTORIES    IX    NEUROLOGY. 

tain  groups  of  muscles  normally  acting  together  will  be 
paralyzed. 

Individual  Nerve  Paralysis.  If  the  lesion  lie  peripheral 
to  the  ple.Kuses,  those  muscles  supplied  by  the  special  nerve 
invoKed  will  alone  be  paralyzed. 

The  same  principles  apply  in  general  to  the  sensory  system. 
The  significance  of  segmental  distribution  as  contrasted  with 
that  of  individual  peripheral  nerves  is  somewhat  greater  in 
the  case  of  sensation  than  in  that  of  motion.  This  segmental 
sensory  involvement  is  especially  important  in  determining 
the  exact  level  of  destructive  lesions  of  the  spinal  cord.  The 
general  distributions  are  indicated  in  the  accompanying  dia- 
grams (Figs.  7,  8),  from  which  it  will  be  seen  that  with  the 
arm  extended  from  the  side,  the  upper  side  of  the  arm  and 
hand  are  supplied  by  the  upper  segments  and  that  the 
anterior  portion  of  the  leg  and  thigh  is  supplied  by  higher 
segments  than  the  posterior  portions.  Owing  to  the  inter- 
position of  the  plexuses,  the  individual  nerve  distribution 
corresponds  roughly  but  not  exactly  to  the  segmental 
distribution. 


SECTION  I. 
PERIPHERAL   NERVES. 

The  phrase  "  peripheral  nervous  system  "  is  to  be  regarded 
rather  as  a  clinical  terminology  than  as  a  statement  of 
anatomical  structure.  The  term  is  ordinarily  used  to  define 
that  portion  of  the  nervous  system  which  lies  without  the 
central  mass  of  the  brain  and  cord.  It  is  evident,  however, 
that  the  neurones  constituting  peripheral  nerves  so  far  as 
they  are  motor  have  origin  from  cell  bodies  within  the  brain 
and  cord,  and  so  far  as  they  are  sensory  send  fibers  into  the 
central  system.  The  term  "  peripheral  nerve  "  is,  therefore, 
one  of  clinical  convenience  rather  than  one  of  anatomical 
accuracy. 

General  Symptomatology.  Inasmuch  as  the  peripheral 
nerves  a:re  mixed,  symptoms  referable  to  them  are  both  motor 
and  sensory,  an  important  diagnostic  distinction  between 
peripheral  and  certain  central  lesions.  Since  both  motion  and 
sensation  are  involved  in  lesions  of  the  peripheral  nerve,  the 
paralysis  resulting  is  of  the  flaccid  atrophic  type  with  added 
disorders  of  sensation  characterized  by  pain  and  tenderness  if 
the  lesion  be  inflammatory  and  by  anesthesia  if  the  lesion  be 
destructive  (seep.  i6). 

Case  I.  N.,  a  married  woman  of  twenty-six,  had  in 
general  been  well  up  to  a  year  before  being  seen.  About  a 
year  previously  she  began  to  have  trouble  with  her  stomach. 
It  was  difficult  for  her  to  retain  food.  For  three  years  she 
had  been  drinking  to  excess, — wine,  whiskey  and  cocktails. 
Four  weeks  before  being  seen  she  was  obliged  to  take  to  her 
bed.  She  claimed  to  have  had  no  alcohol  for  five  or  six  weeks. 
She  was  vomiting.  A  few  days  previously  she  had  had  a 
transient  diplopia  with  some  blurring  of  vision,  but  without 
headache.  For  four  days  she  had  noticed  pain  and  numbness, 
especially  of  the  legs,  extending,  however,  in  some  degree  to 
the  arms. 

23 


24  CASE   HISTORIES   IN   NEUROLOGY. 

Examination  showed  normal  pupils  and  no  cranial  nerve 
palsies.  In  the  arms  there  was  some  pain  on  deep  pressure 
over  the  musculospiral  ner\es.  Her  hands  felt  numb,  but 
objectively  there  was  no  disorder  of  sensation.  The  hand 
grasp  was  good.  The  abdomen  was  painful  on  general  pres- 
sure and  there  was  no  abdominal  reflex.  The  liver  was  not 
noticeably  increased  in  size.  In  the  legs  there  was  marked 
tenderness  over  the  anterior  crural  and  sciatic  nerves,  with 
probable  blunting  of  sensation  in  the  legs  and  distinct  dis- 
turbance of  the  sense  of  position  in  the  toes.  The  knee  jerks 
were  lost;  there  was  no  clonus,  Achilles  or  plantar  reflex. 
Flexion  of  the  ankle  was  imperfect,  the  legs  were  weak.  There 
was  no  sphincter  disturbance.  She  complained  of  failing 
memory. 

Diagnosis.  In  view  of  the  history  of  alcoholic  indulgence 
and  the  supervening  symptoms,  this  case  is  undoubtedly  one 
of  general  Neuritis  due  to  alcohol.  In  favor  of  this  diagnosis 
is  the  weakness  and  tenderness  over  nerve  trunks  together 
with  slight  objective  but  predominant  subjective  disorder  of 
sensation  without  disturbance  in  pupillary  reaction  or  in  the 
control  of  the  sphincters.  The  lost  deep  reflexes  are  ex- 
plained by  an  interruption  of  the  reflex  arc  through  injury  to 
the  mixed  nerve  (see  page  14).  In  favor  also  of  the  diagnosis 
of  neuritis  is  the  general  muscular  weakness ;  failing  memory 
and  transient  diplopia,  although  not  characteristic  of  un- 
complicated neuritis,  are  not  inconsistent  with  that  diagno- 
sis. 

Prognosis  and  Treatment.  Abstinence  from  alcohol  to- 
gether with  supportive  and  general  hygienic  treatment,  com- 
bined with  strychnia  and  massage  in  the  later  stages,  usually 
results  in  cure.  If  neglected,  the  paralysis  may  become 
complete,  contractures  are  apt  to  develop  during  convales- 
cence, and  in  certain  severe  cases  some  permanent  motor 
defect  may  remain,  due  to  the  retrograde  degeneration  of  the 
cells  of  origin  of  the  motor  nerves  in  the  ventral  horns  of 
the  cord. 


PERIPHERAL   NERVES.  25 

Case  2.  E,,  thirty-four  years  old,  was  first  seen  Septem- 
ber 26,  1904.  He  was  a  gambler  and  "  politician  "  and  had 
indulged  in  all  sorts  of  excesses  since  youth.  He  had  un- 
doubtedly had  syphilis.  For  the  past  ten  years  he  had  taken 
alcohol  in  great  excess,  averaging  for  the  previous  five  years 
about  fifteen  drinks  of  whiskey  a  day.  About  six  years  before, 
a  diagnosis  of  tabes  dorsalis  had  been  made  by  a  physician 
of  high  standing.  He  improved,  however,  but  four  years  ago 
was  again  in  bed  with  difficulty  in  walking.  For  some  years 
he  had  had  sharp  pains,  described  as  a  sensation  of  hot  iron 
boring  into  the  flesh.  For  several  weeks  past  he  had  had 
increasing  ataxia,  finally  preventing  his  standing  without 
assistance.  There  was  no  complaint  of  sphincter  disorder  and, 
except  for  some  general  weakness,  he  was  not  conscious  of 
loss  of  muscular  strength. 

Examination  showed  a  normal  light  and  accommodative 
response.  There  was  an  excessive  swaying  with  the  eyes 
closed  (Romberg  sign)  and  much  objective  disturbance  of 
sensation  in  the  feet,  legs  and  thighs.  There  was  also  disorder 
of  the  sense  of  position  of  the  toes.  The  knee  jerks  were  absent. 
There  was  no  plantar  or  Achilles  reaction.  The  abdominal 
and  epigastric  reflexes  were  obtained.  Both  arms  and  legs 
were  highly  ataxic  and  the  hands  also  were  somewhat  numb. 
When  supported  on  both  sides,  he  walked  with  a  typically 
ataxic  gait.  There  was  a  slight  apparent  loss  of  memory,  but 
no  slurring  of  words  and  no  defect  of  speech  suggestive  of 
dementia  paralytica. 

A  diagnosis  of  tabes  was  made  and  Fraenkel  coordinative 
exercises  prescribed.  His  improvement  was  rapid.  On  May 
16,  about  eight  months  after  the  first  visit,  he  had  practically 
recovered.  Examination  at  that  time  was  in  general  as  fol- 
lows: 

There  had  been  some  lancinating  pain  in  the  shoulder  and 
occasionally  in  the  right  foot,  especially  in  damp  weather. 
The  sense  of  numbness  had  practically  disappeared;  his 
memory  was  restored ;  there  was  no  ataxia  of  the  arms ;  no 
Romberg  sign;  the  knee  jerks  were  distinctly  present,  though 
not  very  active.  The  pupils  were  rather  wide,  but  reacted 
properly.     Slight  pain  on  deep  pressure  was  noted  in  the 


26  CASE   HISTORIES    IN    NEUROLOGY. 

right  calf  and  about  the  ankles.  Sense  of  position,  pain  and 
contact  in  the  feet  were  normal.  About  three  months  later 
still  further  improvement  was  apparent.  There  was  no 
sensation  of  numbness,  no  more  shooting  pains,  no  Romberg; 
the  knee  jerks  were  active.  There  was,  however,  slight 
tenderness  on  deep  pressure  in  the  left  calf,  with  an  occasional 
cramp  and  dull  pain. 

Diagnosis.  In  this  case  a  wholly  erroneous  diagnosis  of 
tabes  was  made,  and  its  importance  lies  in  this  possibility. 
The  improvement  and  recovery  show  that  the  condition  was 
due  to  alcohol,  although  so  closely  resembling  tabes  in  its 
symptomatology.  It  is  a  good  example  of  so-called  Peripheral 
Pseudo-tabes  and  illustrates  certain  points  common  to  a 
peripheral  and  central  lesion.  Absent  knee  jerks,  subjective 
and  objective  disorders  of  sensation,  together  with  the 
Romberg  sign,  sharp  pains  and  uncertainty  of  gait,  are  all 
common  to  the  two  conditions.  Argyll-Robertson  pupils 
(failure  to  respond  to  light  with  retained  accommodation) 
and  sphincter  disorders  do  not  occur  in  peripheral  neuritis 
and  did  not  occur  in  this  case.  It  is,  however,  possible  for 
tabes  to  run  its  course  without  involvement  of  the  light 
reflex,  hence  the  absence  of  this  sign  alone  should  not  be 
given  undue  weight  if  other  signs  point  to  tabes.  The  ab- 
sence of  the  sphincteric  disorder  should  be  given  more  weight 
in  arriving  at  a  diagnosis.  The  case  furthermore  demon- 
strates that  lancinating  pains  very  characteristic  of  tabes 
may  occur  in  identical  form  in  peripheral  neuritis.  Motor 
weakness  and  pain  on  deep  pressure  over  the  nerve  trunks, 
together  with  sensitiveness  of  the  skin,  were  not  conspicuous 
and  hence  confused  the  diagnosis.  The  outcome  of  the  case 
in  recovery  taken  in  conjunction  with  an  adequate  antecedent 
history  of  alcoholic  excess,  and  especially  the  return  of  the 
knee  jerks,  must  be  regarded  as  decisive  evidence  that  the 
condition  was  a  neuritis  rather  than  tabes,  although  a  slight 
suspicion  may  still  be  permitted  that  a  combination  of  the 
t\vo  conditions  may  have  existed. 

Prognosis.     The  patient  ultimately  recovered  completely. 

Treatment.  Withdrawal  of  alcohol  and  general  hygienic 
measures  in  this  case  resulted  in  apparent  cure. 


PERIPHERAL   NERVES.  2/ 

Case  3.  U.,  an  unmarried  work-girl  of  twenty-two,  took 
Paris  green  with  suicidal  intent  September  7,  1907.  She  was 
taken  to  a  hospital,  unconscious.  On  recovering  conscious- 
ness she  had  much  epigastric  pain,  together  with  much  general 
pain;  she  was  distressed  by  food;  her  temperature  was  99, 
pulse  96,  respiration  26.  She  complained  of  a  burning  sensa- 
tion extending  from  her  throat  to  her  stomach,  with  nausea. 
In  five  or  six  days  there  was  a  gradual  loss  of  power  in  the 
hands  and  arms,  followed  by  a  similar  condition  in  the  legs, 
associated  with  much  pain. 

Examined  about  two  months  later,  the  following  conditions 
were  noted.  The  pupils  were  normal  and  there  was  no  involve- 
ment of  any  cranial  nerve.  There  was  extreme  paralysis 
of  the  extremities,  the  legs  being  somewhat  more  affected 
than  the  arms.  The  arms  and  hands  showed  the  most  ex- 
cessive wasting.  Movements  of  the  shoulder  were  possible, 
at  the  elbow  very  slight,  and  practically  lost  in  the  hands. 
The  fingers  of  the  left  hand  could  be  slightly  flexed ;  there  was 
complete  wrist  drop  on  the  right;  almost  complete  on  the  left. 
There  was  extreme  pain  over  all  the  nerve  trunks  and  over  the 
muscles.  Pain,  temperature  and  sense  of  position  were  all 
reduced  in  both  hands.  The  arm  reflexes  were  not  obtained. 
Except  for  general  emaciation,  the  body  showed  no  definite 
atrophy.  There  was  no  abdominal  reflex.  The  legs  were 
wasted  almost  to  the  last  degree.  There  was  slight  flexion 
and  extension  at  the  hips  and  knees,  with  complete  foot-drop 
on  both  sides;  movements  of  the  feet  were  impossible.  The 
knee  jerks  were  lost;  there  was  no  Babinski,  plantar  or  Achilles 
reflex.  On  passive  movement  there  was  complaint  of  extreme 
pain,  and  the  nerve  trunks  were  everywhere  sensitive.  With 
some  difficulty  she  was,  however,  able  to  sit  up.  The  heart 
showed  nothing  abnormal.  Later,  under  persistent  treatment 
by  massage  and  exercises,  she  improved  materially  and 
finally  was  able  to  feed  herself  with  her  left  hand  to  some 
degree  and  moved  that  arm  with  increasing  freedom.  On 
December  30  she  was  still  unable  to  stand  and  complained 
of  tingling  and  pain  in  the  hands  and  feet.  Subsequently 
she  has  improved  still  more,  but  to  exactly  what  degree  is  not 
known.    The  sphincters  were  not  involved. 


28  CASE  HISTORIES   IN   NEUROLOGY. 

Diagnosis.  The  effect  of  arsenic  in  poisonous  but  not 
fatal  doses  is  well  shown  in  this  case  of  generalized  Neuritis 
following  the  ingestion  of  Paris  green  in  sufficient  quantity 
to  produce  unconsciousness.  The  extreme  atrophy  of  the 
muscles  in  this  case,  reducing  the  patient  practically  to  a  skele- 
ton, with  lost  reflexes  and  pain,  but  with  a  remarkable  sparing 
of  the  cranial  ners^es,  is  again  characteristic  of  a  multiple 
peripheral  neuritis.  Freedom  of  the  sphincters  is  also  note- 
worthy. 

Prognosis.  The  prognosis  of  this  case  is  good  as  regards 
life,  but  it  is  probable  that  the  peripheral  axones  were  so 
severely  afifected  that  their  cells  of  origin  will  be  permanently 
injured.     In  such  instances,  certain  muscular  defects  persist. 

Treatment.  Massage  and  passive  movements,  gentle  at 
first,  and  later  more  vigorous,  resulted  in  this  case  in  decided 
improvement.  (See  also  general  remarks  on  the  treatment 
of  peripheral  lesions.) 


PERIPHERAL   NERVES.  29 

Case  4.  R.,  a  married  man  of  sixty-three,  noticed  that  his 
hands  were  numb  during  the  latter  part  of  1 909.  The  early  part 
of  January  the  numbness  had  extended  to  his  feet.  He  felt 
somewhat  nauseated,  but  did  not  vomit.  He  had  no  tempera- 
ture ;  his  pulse  was  about  120;  his  respiration,  heart  and  lungs 
normal.  The  liver  extended  to  about  one  inch  below  the  costal 
border.  He  was  a  very  large  eater  and  weighed  235  lb.  He 
did  not  smoke  and  gave  no  history  of  alcohol  in  excess. 
The  urine  was  negative  and  the  bowels  sufficiently  normal. 
The  numbness  and  weakness  increased  steadily  so  that  early 
in  January  he  was  hardly  able  to  get  out  of  bed. 

Examination  showed  a  man  mentally  perfectly  normal, 
but  practically  helpless.  There  was  no  lead  line  on  the  gums 
nor  had  there  been  a  history  of  colic.  The  pupils  were  equal 
and  normal  in  all  respects.  The  cranial  nerves  showed  no 
abnormality  beyond  a  slight  deafness  of  long  standing.  There 
was  no  headache  or  other  cerebral  symptom.  The  arms  were 
very  weak  and  all  movements  of  the  hands  and  arms  were  per- 
formed with  difficulty.  There  was  definite  atrophy,  especially 
of  the  small  hand  muscles.  There  was  pain,  though  not 
extreme,  on  deep  pressure  over  the  upper  arm,  with  definite 
blunting  of  sensation  and  marked  ataxia  of  the  hands.  The 
abdominal  reflexes  were  not  obtained.  There  was  some  possi- 
ble dulling  of  sensation  below  the  umbilicus.  There  was  no 
sphincter  disorder  whatever.  The  legs  were  both  extremely 
weak,  with  considerable  pain  on  deep  pressure  over  the 
sciatic  nerves.  The  knee  jerks  were  lost,  the  plantar  reflexes 
not  obtained ;  there  was  no  Achilles  reflex  and  no  clonus.  There 
was  marked  objective  numbness  of  the  feet,  growing  gradually 
less  up  the  legs,  with  marked  disorder  of  the  sense  of  position 
in  the  toes.  He  was  unable  to  stand.  There  was  no  pain  while 
lying  still.    The  blood  pressure  was  130. 

Diagnosis.  This  case  is  evidently  one  of  Multiple  Neuritis, 
but  of  uncertain  etiology  in  view  of  the  fact  that  an  excessive 
use  of  alcohol  is  denied.  In  susceptible  persons,  however, 
the  steady  use  of  small  amounts  of  alcohol  over  long  periods 
of  time  is  undoubtedly  sufficient  to  produce  an  ultimate 
neuritis.  The  cranial  nerves  are  rarely  affected  in  neuritis 
of  this  general  type  for  reasons  which  have  not  been  definitely 


30  CASE  HISTORIES   IN  NEUROLOGY. 

established.  Lead  poisoning  is  seldom  associated  with  the 
degree  of  pain  and  sensory  disturbance  which  this  patient 
presented. 

Prognosis.  For  a  time  the  condition  grew  decidedly  worse, 
then  improvement  began,  which  has  resulted  in  practically 
complete  restoration  to  health.  In  these  cases  the  tendency 
toward  recovery  is  strong. 

Treatment.  The  patient  was  kept  in  bed,  alcohol  was 
entirely  withdrawn,  and  massage  and  electricity  used. 


PERIPHERAL  NERVES.  3 1 

Case  5.  O.,  forty-two,  a  farmer,  married,  had  been  well 
until  about  October  i,  1907.  He  then  noticed  weakness  of 
the  fingers  in  milking.  Both  hands  were  affected,  but  the  left 
slightly  more  than  the  right.  There  was  no  pain.  He  was 
also  much  troubled  in  walking,  through  weakness.  The  ends 
of  the  fingers  seemed  to  be  numb.  Finally  he  was  unable  to 
lift  objects  or  to  use  his  hands  for  fine  movements,  such, 
for  example,  as  currying  a  horse.  There  was  no  difficulty  in 
micturition,  no  venereal  history,  no  alcohol  or  tobacco. 
He  slept  well  and  had  some  headache.  The  bowels  moved 
regularly. 

The  examination  gave  a  good  light  and  accommodative 
response  with  normal  fields.  Air  conduction  for  watch  tick 
was  six  inches  on  the  right,  about  a  foot  on  the  left.  He 
had  had  suppuration  in  both  ears.  Other  cranial  nerves  were 
uninvolved.  The  heart  was  negative,  the  pulse  80,  regular, 
with  slightly  hardened  arteries.  The  muscles  about  the 
shoulder  were  normal  and  the  movements  free.  There  was 
also  no  evidence  of  muscular  defect  at  the  elbows  or  in  the 
forearm.  The  skin  of  the  hands  was  very  coarse  and  thick, 
evidently  from  work  and  exposure.  There  was  evidence  of 
atrophy  of  the  muscles  of  both  hands.  Extension  was  weak; 
flexion  as  shown  by  hand  grasp  was  also  weak;  the  ulnar 
movements  were  imperfectly  performed.  There  was  a  ten- 
dency to  flexor  contraction  of  the  fingers.  The  elbow  reflexes 
were  slight;  the  wrist  reflexes  not  obtained.  Sensation 
in  the  hands  was  preserved  for  temperature  and  for  contact 
and  presumably  also  for  pain,  although  a  prick  seemed  blunted, 
it  was  supposed  on  account  of  the  roughness  of  the  skin. 
There  was  no  pain  over  the  nerve  trunks;  the  liver  was  of  nor- 
mal size;  the  abdomen  showed  no  abnormality  beyond  the  fact 
that  there  was  no  abdominal  reflex.  All  movements  of  the  legs 
were  possible,  and  there  was  no  visible  atrophy.  The  knee 
jerks,  Achilles  and  plantar  reflexes  were  normal,  and  there  was 
no  clonus.  Sensation  of  the  feet,  including  sense  of  position, 
was  unimpaired.  There  was  no  Romberg  or  ataxia  either  of 
the  arms  or  legs,  although  he  complained  of  a  staggering 
gait,  which  he  attributed  to  general  weakness.  He  was 
unable  to  drive  because  the  reins  slipped  through  his  fingers. 


32  CASE  HISTORIES   IN    NEUROLOGY. 

Diagnosis.  The  erroneous  diagnosis  of  progressive  muscular 
atrophy  of  the  spinal  type  was  made  in  this  case  from  the 
insidious  onset  of  the  weakness  involving  primarily  the  small 
muscles  of  the  hands  without  sensory  disturbances.  The  blood 
and  urine  should  have  been  examined  to  determine  the  pres- 
ence of  anemia,  possible  stippling  of  the  blood  corpuscles 
and  the  presence  or  absence  of  lead.  These  examinations  were 
later  made  at  the  hands  of  another  physician,  who  demon- 
strated anemia,  no  mention  being  made  of  stippling  and  lead 
in  the  urine.  It  is  altogether  probable,  therefore,  that  the  pa- 
tient was  suffering  from  Lead  Poisoning  which  had  led  to  a  con- 
dition simulating  progressive  muscular  atrophy.  The  differ- 
entiation between  these  two  affections  is  important  and  often 
difficult,  in  certain  cases  (as  in  this)  being  definitely  determined 
only  by  the  actual  finding  of  lead  in  the  excretions.  The  ex- 
istence of  colicky  pain  is  of  more  importance  in  arriving  at  a 
diagnosis  than  the  lead  line  on  the  gums,  which  in  well-kept 
teeth  often  does  not  appear.  Lead  aft'ects  peculiarly  the  motor 
portion  of  the  mixed  nen-e,  hence  the  absence  of  sensory  dis- 
orders should  not  preclude  the  diagnosis  of  lead  poisoning. 

Prognosis.  The  outcome  in  this  case  is  uncertain  owing 
to  the  extent  to  which  the  muscular  degeneration  has  pro- 
gressed. The  patient  was  seen  and  examined  again  about  three 
years  later.  He  was  then  almost  entirely  helpless,  unable  to 
walk  or  feed  himself,  but  still  without  sensory  disturbances. 
Under  hospital  care  and  mechanical  treatment  he  again  im- 
proved considerably  and  was  able  to  use  his  arms  and  hands 
with  some  effectiveness.  If  the  condition  be  due  primarily  to 
lead  poisoning,  as  seems  probable,  it  should  be  borne  in  mind 
that  a  progressive  muscular  atrophy  may  supervene  on  this 
basis.  The  ventral  horn  cells  are  almost  certainly  involved 
and  a  complete  restoration  of  power  is  not  to  be  expected. 

Treatment.  The  patient  improved  at  first  under  iodide 
of  potash  given  in  relati^'ely  small  doses,  five  to  fifteen  grains. 
Mechanical  treatment  of  the  muscles  in  the  later  stages  by 
means  of  Zander  apparatus  also  resulted  in  marked  improve- 
ment. Effective  treatment  of  lead  poisoning  consists,  first, 
in  the  elimination  of  the  lead  and,  secondly,  in  the  restoration 
of  muscular  power  through  mechanical  means. 


PERIPHERAL    NERVES.  33 

Case  6.  L.,  thirty-eight  years  old,  the  mother  of  one  child 
of  fifteen  years,  had  been  married  twice,  the  second  time  two 
years  before.  She  had  been  a  hard-working  woman,  but  was 
neurotic  in  type  and  hysterical  as  a  young  girl.  Previous  to 
her  second  marriage  she  was  apparently  well.  A  year  before 
she  was  seen,  in  May,  1907,  she  was  greatly  shocked  by  a 
shooting  accident  which  occurred  in  her  house.  In  August, 
1906,  her  left  elbow  and  left  knee  became  painful  and  swollen 
but  were  relieved  by  the  administration  of  salicylates,  except- 
ing that  the  left  elbow  remained  stiff,  with  imperfect  exten- 
sion. More  recently  her  jaw  had  swollen  and  been  painful 
and  she  had  had  much  headache.  Her  pulse,  she  thought,  had 
always  been  slow.  She  had  also  noticed  numbness  and  prick- 
ling, especially  of  the  hands,  feet  and  legs.  For  a  week  past 
she  had  not  been  able  to  work  or,  in  fact,  to  stand.  Her  second 
marriage  was  supposed  to  be  happy. 

Examination  showed  widely  dilated  pupils  with  normal 
light  and  accommodation  reactions  and  unconstricted  visual 
fields.  The  face  appeared  rather  expressionless,  but  there  was 
no  lesion  of  the  facial  or  any  other  cranial  nerves.  There  had 
been  some  complaint  of  soreness  of  the  throat  which  an 
examination  did  not  explain.  For  three  or  four  weeks  she 
had  had  definite  nocturnal  headaches,  chiefly  frontal  and 
occipital.  There  was  a  sore  spot  apparently  referable  to  the 
bone  under  the  left  breast.  The  heart  was  normal,  the  pulse 
80,  and  regular.  The  arms  were  weak  and  painful  on  pressure 
over  the  large  nerves.  There  was  no  apparent  ataxia  or 
objective  disorder  of  sensibility  in  spite  of  much  complaining 
on  her  part.  The  arm  reflexes  were  not  obtained.  The  ab- 
dominal reflex  was  present.  There  were  no  knee  jerks,  no 
Achilles  response  and  slight  plantar  reaction.  The  legs  were 
very  weak,  making  walking  impossible,  and  there  was  much 
pain  on  pressure  over  the  nerves  of  the  legs  and  thighs  with- 
out at  this  time  objective  disorders  of  sensation.  The  bowels 
were  costive,  but  there  was  no  urinary  disturbance.  Axillary 
and  inguinal  glands  were  doubtfully  palpable.  Her  mind  was 
clear. 

A  second  visit,  twelve  days  after,  showed  the  condition 
essentially  unchanged,  but  worse   rather   than   better.      No 


34  CASE    HISTORIES    IN    NEUROLOGY. 

epigastric  or  abdominal  reflex  was  obtainable,  there  was  double 
foot-drop  and  considerable  loss  of  sense  of  position  in  the 
feet  and  toes.    In  general,  she  was  very  weak. 

Diagnosis.  This  case,  although  somewhat  obscure  and 
complicated  by  certain  neurotic  tendencies,  was  undoubtedly 
a  Neuritis,  presumably  on  the  basis  of  a  syphilitic  infection, 
although  the  latter  was  never  absolutely  demonstrated.  In 
such  a  case,  the  more  recently  discovered  Wassermann  reac- 
tion is  of  the  greatest  service  in  establishing  the  etiological 
factor  and  in  determining  subsequent  treatment.  The  weak- 
ness, loss  of  reflexes,  pain  on  pressure  over  nerve  trunks,  with 
intact  sphincters,  is  enough  to  establish  a  definite  diagnosis 
of  peripheral  neuritis. 

Prognosis.  Ultimate  but  very  gradual  recovery.  The 
patient  is  now  well  and  leading  an  active  life. 

Treatment.  Iodide  of  potash  and  mercury  were  advised, 
but  were  at  first  not  well  borne.  By  persevering,  however, 
she  was  finally  able  to  take  a  large  amount  of  both  drugs. 
In  such  cases  iodide  of  potash  should  be  given  up  to  150-200 
grains  daily,  and  mercury,  preferably  by  inunction,  to  the 
point  of  toleration. 


PERIPHERAL    NERVES.  35 

Case  7.  O.,  an  unmarried  woman  of  forty-five,  gave  a  his- 
tory of  rheumatism.  Her  present  trouble  dated  back  about  a 
month.  She  had  been  working  hard,  both  mentally  and  physi- 
cally, and  had  noticed  a  lackof  power  of  flexion  of  the  left  hand 
and  fingers,  with  pain  about  the  inner  condyle  of  the  left  elbow, 
down  the  ulnar  side  of  the  forearm  and  on  the  flexor  surface 
of  the  left  wrist  on  motion  of  the  fingers  or  wrist.  When  at 
rest  there  was  no  pain.  There  was  apparent  "  tendon  grating  " 
on  flexion  and  extension  of  the  carpus.  The  temperature 
had  been  somewhat  elevated.  The  pain  was  not  sufficient 
to  prevent  sleep,  but  was  a  source  of  considerable  annoyance 
and  incapacity. 

Examination  showed  the  whole  left  arm  and  hand  to  be 
weak  and  painful.  There  was  distinct  pain  on  pressure, 
especially  over  the  median  and  musculospiral  nerves  in  the 
upper  arm.  The  brachial  plexus  was  apparently  not  sensitive 
to  pressure.  Various  movements  of  the  hand  were  weak,  the 
skin  was  puffy,  sensation  was  blunted  to  pain  and  to  hot  and 
cold.  There  was  evidence  also  of  a  tenosynovitis.  Electri- 
cal examination  gave  a  marked  quantitative  diminution  to 
faradism,  especially  in  the  small  thumb  muscles,  which  showed 
the  greatest  degree  of  weakness.  There  was  also  a  marked 
quantitative  diminution  to  the  galvanic  current,  but  the  con- 
traction from  the  negative  pole  was  greater  than  that  from  the 
positive.  It  was,  however,  slow  in  character.  At  the  end  of 
six  months  the  patient  had  not  entirely  recovered. 

Diagnosis.  The  diagnosis  in  this  case  was  Neuritis  involv- 
ing nerves  derived  from  the  brachial  plexus.  The  character- 
istic symptoms  and  signs  of  a  neuritis  were  present, —  pain 
on  movement,  pain  on  pressure  over  the  nerve,  objective 
disturbance  of  sensation,  motor  weakness,  altered  electrical 
reactions,  in  this  case  constituting  a  partial  R.  D.  (seep.  15). 
There  Is  no  possibility  of  confusing  such  a  case  with  a  central 
lesion  since  motion  and  sensation  were  both  Involved  and  there 
was  distinct  pain  on  pressure  over  the  nerve.  The  differential 
diagnosis  from  syringomyelia  (see  Case  51)  Is  determined 
essentially  by  the  lack  of  dissociation  of  sensation  and  by  the 
presence  of  pain  on  pressure. 

Prognosis.     The  outcome  Is  good  since  there  is  no  evidence 


36  CASE    HISTORIES    IN    NEUROLOGY. 

of  a  persistent  cause,   e.  g.,  axillary  pressure  through  tumor 
or  aneurism. 

Treatment.     Expectant.     (See     also     general     treatment, 

p.  6i.) 


PERIPHERAL   NERVES.  37 

Case  8.  G.,  a  student  of  twenty,  was  seen  June  i,  1910. 
Following  pneumonia  with  pleurisy  he  developed  a  sore 
shoulder  and  weak  arm  and  hand  on  the  right.  He  had  pain 
from  the  first  but  It  did  not  extend  down  the  arm.  As  he  re- 
covered from  the  pneumonia  the  hand  and  arm  remained  weak 
and  this  condition  has  not  Improved. 

Examination  showed  pain  on  deep  pressure  in  the  axilla, 
but  not  to  any  degree  over  the  nerves  of  the  upper  or  lower 
arm.  The  right  arm  In  general  was  about  half  an  inch  less 
in  circumference  than  the  left  at  various  points.  There  was 
no  shoulder-joint  Involvement  nor  manifest  disturbance  of 
the  upper  arm.  There  was  no  objective  disorder  of  sensation, 
but  a  distinct  subjective  sense  of  numbness  In  the  ulnar  dis- 
tribution. The  arm  reflexes  were  retained.  Atrophy  was 
marked  In  the  hand,  both  of  the  Interossel  and  thenar  muscles. 
Extension  of  the  hand  was  possible,  but  the  grasp  was  very 
weak,  as  were  the  ulnar  movements  (ab-  and  adduction  of  the 
fingers;  extension  of  the  terminal  phalanges).  The  little  finger 
and  thumb  could  not  be  approximated.  Electrical  examina- 
tion showed  a  slow  galvanic  response,  AnC  =  CaC,  with 
reduced  faradic  reaction;  partial  R.  D. 

Diagnosis.  This  case  is  presumably  a  Brachial  Neuritis 
following  an  Infectious  process.  It  differs  from  Case  7  in  that 
the  brachial  plexus  Is  Itself  sensitive  to  pressure  and  the  motor 
disturbances  are  much  more  conspicuous  In  the  hand  than 
the  sensory.  The  extreme  atrophy  of  the  small  muscles  of  the 
hand  Is  suggestive  of  a  progressive  muscular  atrophy  of  the 
spinal  type,  particularly  since  the  objective  disturbance  of 
sensation  in  the  hand  is  exceedingly  slight.  The  electrical 
reactions  are  consistent  with  either  condition.  On  the  other 
hand,  the  tenderness  over  the  brachial  plexus,  the  fact  that 
pain  has  been  somewhat  conspicuous  in  the  history  and  the 
wholly  unilateral  character  of  the  affection  all  point  strongly 
to  the  probability  of  a  neuritis  of  a  degenerative  type. 

Prognosis.  If  the  supposition  of  a  localized  neuritis  be 
correct,  complete  recovery  is  to  be  expected. 

Treatment.  In  this  case  it  Is  more  important  to  treat  the 
patient's  general  condition  than  the  local  disturbance.  Pains 
should  be  taken  to  prevent  the  possibility  of  finger  contractures. 


38  CASE   HISTORIES    IiN    NEUROLOGY. 

Case  9.  I.,  twenty-six  years  old,  married,  was  well  during 
her  first  pregnancy.  The  labor  was  difficult  and  the  baby  was 
stillborn.  She  made  a  good  recovery  with  a  slight  temperature 
for  a  iew  days.  Immediately  after  recovering  from  ether, 
taken  during  the  delivery  of  the  child,  she  complained  of 
numbness  at  the  front  and  side  of  the  right  thigh  and  later 
of  pain  under  the  knee  and  extending  to  the  foot,  with  numb- 
ness of  the  foot.  It  became  difficult  for  her  to  extend  her  leg, 
and  about  three  days  later,  when  examined,  the  right  leg  was 
still  weak,  there  was  much  complaint  of  pain  on  movement 
of  the  leg,  the  calf  muscles  were  flabby  and  movements  of 
the  foot  were  markedly  hindered.  There  was  diminished  pain 
sense  in  the  foot  and  loss  of  sense  of  position  of  the  toes. 
There  was  also  pain  in  the  anterior  portion  of  the  thigh  in  the 
region  supplied  by  the  anterior  crural  nerve.  There  was 
definite  pain  on  deep  pressure  over  the  nerves  on  the  back 
of  the  leg  and  in  the  popliteal  space.  The  patient  was,  in 
general,  neurotic,  and  there  was  some  slight  hemianesthesia. 

Diagnosis.  The  disturbance  in  this  case  was  essentially 
in  the  distribution  of  the  right  sciatic  nerve  although  the  ante- 
rior crural  distribution  was  slightly  Involved.  Pain  on  pressure 
and  on  movement,  together  with  objective  loss  of  sensation 
in  the  terminal  branches  of  the  sciatic  nerve,  with  considerable 
motor  weakness,  are  characteristic  of  so-called  Sciatica.  It 
is  to  be  presumed  that  pressure  In  the  pelvis  during  the  deliv- 
ery of  the  child  was  the  direct  cause  of  the  sciatic  involvement 
in  this  case.  It  is  of  interest  that  even  in  such  cases  of  appar- 
ently local  pressure,  signs  of  mild  Inflammation  appear  at  a 
long  distance  from  the  point  of  Injury. 

Prognosis  and  Treatment.  Recovery  under  rest,  strychnia, 
massage  and  electricity  was  slow,  —  six  months  to  a  year, 
—  but  ultimately  complete. 


PERIPHERAL    NERVES.  39 

Case  10.  C,  a  man  of  sixty,  had  for  some  years  complained 
of  pain  in  the  lower  abdomen.  He  saw  various  physicians, 
but  nothing  was  accomplished  for  its  relief.  This  pain 
gradually  improved  spontaneously.  In  June,  1907,  while 
using  a  new  automobile  under  considerable  nervous  strain, 
he  noticed  pain  in  the  left  sciatic  region,  which  had  increased 
in  spite  of  treatment;  fixation  of  the  sacro-iliac  joint  had  not 
resulted  in  improvement;  the  pain  was  especially  severe  at 
night.  The  patient's  father  had  died  twelve  years  before, 
presumably  of  rectal  cancer.  It  is  probable  that  the  patient's 
original  abdominal  pain  was  the  result  of  suggestion  rather 
than  indicative  of  the  disease  which  later  developed. 

Examination  showed  the  spine  to  be  somewhat  rigid, 
especially  in  the  lower  part.  Hyperextension  of  the  left  leg 
was  less  readily  performed  than  of  the  right.  There  was 
pain  behind  the  knee.  The  pupils  were  equal,  normal  in 
reaction  and  fields.  The  cranial  nerves  were  free;  tongue 
straight,  moist  and  clean.  The  arms  showed  no  abnormality. 
The  pulse  was  ']2,  slightly  irregular.  The  liver  was  of  normal 
size,  the  abdomen  soft,  with  no  painful  areas;  no  tumor  could 
be  felt  on  external  palpation.  The  abdominal  and  cremaster 
reflexes  were  normal.  The  legs  showed  no  atrophy  and  were 
of  good  strength.  There  was  some  blunting  of  sensation  over 
the  whole  sciatic  area  of  the  left  leg  and  definite  pain  on 
deep  pressure  over  the  nerve  throughout  its  course.  The 
knee  jerks  were  normal  and  equal,  with  no  clonus  and  with 
normal  plantar  and  Achilles  response.  The  movements  of 
the  foot  were  free  and  the  sense  of  position  good.  He  walked 
without  limp;  the  spine  was  not  tender;  the  sphincters 
were  normal.  The  pain  was  dull  in  character,  but  at  times 
exceedingly  distressing.  It  did  not,  however,  extend  into  the 
right  leg  at  this  time.  Later  rectal  examination  disclosed  a 
tender  area  over  the  sacrum  which  finally  was  definitely- 
diagnosticated  as  a  sarcomatous  growth,  inoperable  in 
character.  The  patient  grew  worse  and  died  within  a  few 
months. 

Diagnosis.  In  this  case  unilateral  sciatic  pain  which  for  a 
time  passed  as  an  ordinary  sciatica  was  due  to  a  Tumor  of 
the  sacrum  invading  the  sciatic  nerve.     The  unusual  feature 


40  CASE   HISTORIES    IX    NEUROLOGY. 

of  the  case  is  the  fact  of  the  long  persistence  of  unilateral 
pain.  Bilateral  sciatic  pain  is  always  strongly  suspicious 
of  a  lesion  within  the  vertebral  canal  since  there  the  nerves 
of  the  two  sides  lie  in  close  proximity  to  each  other.  In  this 
instance  a  definite  diagnosis  of  the  cause  of  the  sciatica  was 
not  to  be  determined  until  a  careful  rectal  examination 
had  been  made 

Prognosis.  The  patient  lived  several  months  after  the 
definite  diagnosis  was  made. 

Treatment.  Operation  was  out  of  the  question  and  the 
Coley  serum  proved  unavailing.  In  such  cases  of  definite 
fatal  termination  and  accompanied  by  extreme  pain,  morphine 
should  be  freely  used. 


PERIPHERAL   NERVES.  4 1 

Case  II.  A.,  a  woman  of  forty-five,  unmarried,  first  had 
pain  over  the  right  sciatic  nerve,  as  she  supposed  from  over- 
exertion. She  was,  however,  unable  to  remember  any  special 
strain.  The  pain  was  at  first  severe  and  grew  worse.  It 
was  entirely  confined  to  the  right  leg.  The  removal  of  a 
uterine  fibroid  did  not  relieve  the  pain  which  was  of  varied 
character,  at  times  sharp  like  a  knife-cut,  and  appearing  in 
different  places  with  soreness  to  the  touch.  There  was  not 
much  pain  below  the  knee.  In  general  she  was  well;  her 
bowels  were  normal  and  the  pain  was  evidently  not  dependent 
upon  their  condition. 

Examination  showed  a  perfectly  healthy  appearing  woman 
without  other  abnormality  than  the  disturbance  in  the  leg. 
In  the  right  leg  there  were  painful  points  at  the  exit  of  the 
sciatic  nerve  from  the  pelvis,  also  in  the  popliteal  space  and 
in  the  thigh.  There  was  less  pain  in  the  calf  and  foot  and  no 
objective  disorder  of  sensation.  Motor  power  was  retained, 
but  with  some  tendency  to  contracture  of  the  posterior  leg 
muscles.  The  knee  jerks  were  normal  and  active.  A  definite 
plantar  reflex  was  not  obtained  on  the  right. 

Diagnosis.  This  case  offers  no  adequate  etiology  for  the 
Sciatica  —  a  very  common  experience.  It  is  doubtful  whether 
the  supposed  muscular  strain  was  sufficient  to  produce  the 
condition.  Such  vague  causes  should  always  be  regarded 
with  extreme  doubt.  A  candid  acknowledgment  of  igno- 
rance is  a  safer  attitude  to  assume. 

Prognosis.     Doubtful  as  to  complete  recovery. 

Treatment.  Avoidance  of  strain,  and  the  general  measures 
laid  down  on  page  6i. 


42  CASE   HISTORIES    IN    NEUROLOGY. 

Case  12.  L.,  thirty-one  years  old,  an  unmarried  woman, 
of  somewhat  neurotic  type,  after  considerable  violent  exercise, 
especially  horseback  riding,  experienced  severe  pain  over  the 
sacrum  particularly  on  the  left  side.  The  pain  improved  and 
except  for  some  discomfort  on  sitting  she  was  apparently 
well  and  gained  in  weight.  For  two  weeks  there  had  been 
tenderness  in  the  coccygeal  region;  she  was  easily  tired; 
walking  was  painful;  there  was  some  pain  also  in  the  left 
leg  and  a  very  tender  point  within  the  rectal  sphincter.  She 
had  noticed  an  accession  of  pain  after  horseback  riding. 

On  examination,  tender  areas  were  found  over  both  sacro- 
iliac joints,  but  especially  on  the  left  side.  There  was  a 
particularly  tender  area  over  the  left  buttock,  slightly  above 
the  sacro-iliac  joint.  There  was  also  pain  on  pressure  over 
the  sciatic  nerve  in  the  thigh,  popliteal  space,  and  at  the 
ankle.  These  painful  points  were  much  more  marked  on  the 
right  than  on  the  left.  Objective  sensation  was  normal  and 
motion  was  unimpaired.  Knee  jerks  were  both  active;  the 
plantar  and  Achilles  reflexes  were  normal.  There  was  no 
ankle  clonus.  The  pulse  was  76,  regular;  pupils  wide  but 
with  normal  light  reaction;  the  patient  was  nervous  in 
appearance  and  manner. 

Diagnosis.  This  case  illustrates  disturbance  in  the  sciatic 
nerve  of  the  nature  of  a  Sciatica  as  a  result  of  a  wrench  of  the 
Sacro-iliac  articulation.  In  sciatica  of  doubtful  etiology  this 
possibility  should  always  be  taken  into  consideration.  The 
diagnosis  is  greatly  assisted  by  pain  referred  to  the  lower 
back,  as  in  this  case,  accompanied  by  certain  limitation  of 
movements  of  the  spine. 

Prognosis  and  Treatment.  The  prognosis  is  good  if 
treatment  by  rest,  avoidance  of  back  strain  and  fixation  of 
the  joint  be  judiciously  employed.  If  neglected  the  pain  is 
likely  to  persist  indefinitely. 


PERIPHERAL    NERVES.  43 

Case  13.  C,  an  unmarried  woman  of  twenty-six,  was 
violently  thrown  from  a  double  runner  while  coasting.  She 
had  various  slight  contusions,  but  excepting  for  the  injury 
about  to  be  described  was  essentially  unhurt.  She  does  not 
know  how  she  struck,  but  immediately  noticed  that  the  right 
arm  was  completely  paralyzed  to  the  shoulder.  The  pain 
was  not  excessive  and  when  seen  in  May,  1903,  three  and 
a  half  months  after  the  accident,  she  was  suffering  no  dis- 
comfort beyond  the  total  loss  of  the  use  of  her  arm.  She 
had  not  improved  in  the  slightest  degree. 

Examination  showed  complete  motor  paralysis  of  the 
muscles  supplied  by  the  right  brachial  plexus  with  asso- 
ciated atrophy  and  electrical  alterations.  The  sensibility 
was  completely  lost  to  a  point  somewhat  above  the  elbow. 
From  there  to  the  shoulder  there  was  some  slight  recognition 
of  pain  stimulus,  increasing  upward.  The  neck  and  back 
were  normal.  On  January  2^] ,  1904,  an  x-ray  showed  atrophy 
of  the  bones  of  the  right  hand.  She  was  then  able  to  flex  and 
supinate  the  right  arm  somewhat  with  the  biceps.  Abduction 
and  inward  rotation  were  also  slightly  possible.  There  was 
reaction  of  degeneration  in  the  interosseous  muscles  of  the 
right  hand  and  in  the  supinator  longus;  CaC  was,  however, 
greater  than  AnC.  In  spite  of  the  fact  that  she  was  able  to 
use  the  biceps  to  some  extent,  no  electrical  reaction  was 
obtained  from  that  muscle.  Under  faithful  treatment 
by  massage  and  electricity  there  was  practically  no  im- 
provement. Operation  was  finally  decided  upon  in  the  hope 
of  restoring  by  nerve  suture  a  part  of  the  function  of  the 
severed  nerves.  On  exposing  the  brachial  plexus,  May  31, 
1904,  the  individual  nerves  were  found  so  badly  damaged 
that  the  anatomical  landmarks  were  completely  lost.  Certain 
sutures  were,  however,  attempted,  with  the  ultimate  result 
after  many  months  of  a  certain  slight  restoration  of  function 
in  the  arm  and  hand. 

In  April,  1905,  there  was  extreme  atrophy  of  the  pectorals, 
deltoid  and  of  the  muscles  below  the  elbow.  Electrical 
reactions  were  very  much  as  before.  The  trapezius  reacted 
well  and  the  pectoralis  major  feebly.  There  was  no  sensation 
below  the  elbow.     Two  years  later  the  condition  had  not 


44  CASE    HISTORIES    IN    NEUROLOGY. 

materially  changed.  There  was,  however,  increased  power 
in  flexion  of  the  biceps  and  the  possibility  of  extension  of  the 
fingers,  with  some  flexion  both  of  the  hand  and  fingers. 
Flexion  of  the  biceps  had  improved.  There  was  still  no 
sensation  below  the  elbow. 

Diagnosis.  The  diagnosis  of  Brachial  Injury  or  destruction 
of  the  plexus  is  not  difficult.  In  this  instance,  the  complete 
loss  of  power  with  the  retention  of  slight  sensation  indicated 
a  very  destructive  lesion  which  the  operation  later  revealed. 
It  is  to  be  noted  that  the  nen-es  given  off  above  the  plexus 
did  not  take  part  in  the  process.  It  occasionally  happens 
that  the  nerve  roots  are  torn  at  their  exit  from  the  spinal  cord. 
The  combination  of  sensory  and  motor  defect  with  atrophy, 
electrical  alterations  and  flaccidity  following  traumatism 
permits  of  no  other  diagnosis  than  injury  to  the  nerves  after 
their  exit  from  the  cord. 

Prognosis.  The  outcome  of  severe  brachial  injuries  such 
as  this  is  not  favorable.  The  degree  of  recover>'  naturally 
depends  upon  the  amount  of  primary  injury.  Operation 
on  the  brachial  plexus  is  difficult,  but  in  skilled  hands  offers 
very  considerable  hope  of  partial  restoration  of  function  as 
shown  in  this  case. 

Treatment.  The  treatment  of  such  injuries  is  through 
electricity,  massage  and  later  surgical  inter\^ention,  particu- 
larly in  those  cases  where  improvement  does  not  take  place. 


PERIPHERAL   NERVES.  45 

Case  14.  A.,  fifteen  years  old,  was  a  first  child.  Instru- 
ments were  used  at  her  delivery.  It  was  noticed  shortly  after 
birth  that  the  left  arm  was  paralyzed,  although  it  showed  no 
sign  of  bruising.  There  was  gradual  improvement,  and  at 
the  age  of  four  or  five  she  had  some  movements  in  the  arm. 
She  had  had  no  pain,  was  in  general  perfectly  well  and  had 
noticed  no  disorder  of  sensation  in  the  affected  arm.  For 
several  years  up  to  the  time  when  examined,  she  had  made  no 
improvement. 

Examination  showed  distinct  weakness  of  the  deltoid, 
biceps,  supinator  longus  and  the  outward  rotators  (teres 
minor  and  infraspinatus)  of  the  left  arm,  with  no  disorder  of 
sensibility.  Deltoid  movements  were  practically  impossible, 
flexion  of  the  arm  was  exceedingly  weak  and  outward  rotation 
very  defective.  She  was  unable  to  feed  herself.  Faradic 
irritability  of  the  muscles  was,   however,  preserved. 

Diagnosis.  This  is  a  typical  severe  case  of  Obstetrical 
Paralysis  of  unusually  long  standing.  The  fact  that  the  labor 
was  difficult,  necessitating  force,  and  that  the  paralysis,  in- 
volving muscles  of  one  arm,  was  immediate,  renders  the 
diagnosis  certain  of  injury  of  the  brachial  plexus  at  birth. 
The  exact  method  of  production  of  this  injury  is  not  definitely 
established.  There  is  no  statement  as  to  the  position  of  the 
child  during  birth,  but  it  is  probable  that  the  brachial  plexus 
was  put  on  the  stretch  in  such  a  way  as  to  yield  at  its  weakest 
point,  which  experience  shows  is  so  localized  that  the  deltoid, 
biceps,  brachialis  anticus,  supinator  longus  and  outward 
rotators  are  commonly  involved. 

Prognosis.  The  outcome  of  obstetrical  paralysis  is  usually 
favorable.  It  rarely  happens  that  it  continues  into  adult 
life  as  in  this  instance.  It  is  probable  that  had  systematic 
treatment  been  employed  at  an  early  age  the  condition 
would  have  been  greatly  ameliorated. 

Treatment.  Mechanical  treatment  even  now  is  desirable, 
designed  not  only  to  maintain  the  nutrition  of  the  affected 
muscles  but  also  to  overcome  the  tendency  to  a  fixed  position 
of  the  hand  and  arm.  Inasmuch  as  the  nerves  are  usually 
injured  but  not  severed,  recovery  is  apt  to  occur  through 
natural  processes  assisted  by  massage  and  similar  measures. 


46  CASE    HISTORIES    IN    NEUROLOGY. 

Case  15.  S.,  a  woman  of  sixty-one,  was  thrown  violently 
to  the  ground  in  connection  with  a  railway  accident.  She 
was  unable  at  once  to  get  up  but  was  not  unconscious.  She 
felt  frightened  and  was  faint,  but  was  without  pain,  and 
thought  herself  uninjured.  Later,  pain  developed  over  the 
left  breast,  and  as  light  separation  of  the  third  rib  from  the 
sternum  was  demonstrated  by  x-ray.  She  had  fallen  on  her 
right  arm  and  shortly  after  the  accident  noticed  marked 
difficulty  in  its  use.  At  first,  she  was  unable  to  raise  it,  and 
although  there  was  no  sufficient  external  sign  of  injury  the  arm 
seemed  helpless.  There  was  a  somewhat  painful  point  at 
the  musculo-spiral  groove.  After  about  two  months,  she 
was  able  to  write  by  placing  her  arm  on  a  table  to  gain  support, 
but  even  then  there  was  difficulty  in  control. 

Examination  showed  normal  pupils  and  normal  reflexes. 
The  rib  had  healed  and  in  general  she  was  well  except  for 
certain  nervous  disabilities  and  a  decided  loss  of  power  in 
the  right  arm.  Abduction  of  the  arm  at  the  shoulder  was 
sharply  limited  on  account  of  pain.  Outward  rotation  was 
also  impossible  for  the  same  reason.  The  pain  was  referred 
to  the  base  of  the  deltoid.  There  was  also  a  distinctly  painful 
point  on  pressure  anteriorly  over  the  shoulder  joint.  Other 
arm  movements  were  possible,  though  somewhat  limited 
through  anticipation  of  pain.  The  nerves  of  the  arm  were 
not  sensitive  on  pressure  and  there  was  no  objective  sensory 
disturbance. 

Diagnosis.  This  case  had  been  referred  with  the  probable 
diagnosis  of  a  brachial  neuritis.  The  difficulty  evidently  is 
Sub-deltoid  Bursitis  as  shown  by  the  cardinal  signs  of  pain 
on  abduction  and  outward  rotation  with  essentially  un- 
impaired capacity  for  other  movements,  together  with  a 
painful  point  over  the  joint  and  pain  referred  chiefly  to  the 
base  of  the  deltoid  on  forced  movements  of  the  arm.  The 
absence  of  objective  sensory  disorder  and  the  peculiar  limi- 
tation of  the  disturbance  precludes  the  possibility  of  a  brachial 
neuritis.  The  differential  diagnosis  from  the  latter  condition 
is  extremely  important. 

Prognosis  and  Treatment.  The  prognosis  of  this  type  of 
bursitis   is   favorable.      Recovery   may  occur  spontaneously 


PERIPHERAL   NERVES.  47 

after  manipulation  either  with  or  without  primarily  breaking 
up  the  adhesions,  or  in  more  severe  cases  by  operative  inter- 
ference, with  extirpation  of  the  bursa.  Whatever  treatment 
is  undertaken  it  is  essential  that  the  adhesions  between 
the  surfaces  of  the  bursa  which  cause  the  difficulty  should 
not  only  be  broken  but  should  be  prevented  from  reforming. 
This  may  be  accomplished  by  forcible  breaking  of  the  ad- 
hesions with  continued  manipulation,  by  maintaining  the 
arm  in  an  abducted  and  outwardly  rotated  position  through 
a  specially  devised  splint,  or  by  removal  of  the  bursa  itself. 
It  is  possible,  also,  that  the  bursa  may  be  obliterated  through 
general  adhesion  of  its  surfaces,  resulting  in  ultimate  cure 
through  an  entirely  natural  process. 


48  CASE   HISTORIES    IN    NEUROLOGY. 

Case  i6.  E.,  twenty-nine  years  old,  married,  a  locomoti\e 
fireman,  gave  the  following  stor>-.  On  July  27,  he  fell  from 
the  locomotive,  striking  his  arm  slightly  below  the  right 
axilla  on  a  steel  projection  in  such  a  way  that  a  cut  was 
occasioned;  requiring  several  stitches  for  its  repair.  In 
sewing  up  the  wound  no  investigation  was  made  of  the 
condition  of  the  nerv^es  beneath.  From  the  time  of  the 
accident  he  had  had  a  complete  wrist-drop  with  a  considerable 
disorder  of  sensation  in  the  radial  distribution  over  the  hand. 
There  was  no  involvement  either  of  the  ulna  or  median 
movements.  Inasmuch  as  sensation  in  the  area  supplied 
by  the  musculospiral  nerv^e  improved  rapidly,  it  was  be- 
lieved that  the  nerve  trunk  had  not  been  severed.  Mechanical 
treatment  by  massage  and  electricity  was  continued  with 
great  faithfulness  until  December  22,  a  period  of  nearly  five 
months.  During  that  period  sensation  improved  practically 
to  th€  point  of  complete  cure,  but  the  wrist-drop  persisted 
essentially  without  improvement.  Operation  was,  therefore, 
advised. 

December  22,  an  incision  five  inches  long  was  made  over 
the  seat  of  the  scar  which  was  not  adherent  to  the  underlying 
tissues  and  showed  a  perfectly  normal  healing.  A  dissection 
was  made  exposing  the  musculospiral  nerve  as  it  passed 
into  the  groove.  It  was  then  found  on  raising  the  nerve  from 
the  groove  that  it  was  irregular  in  outline  and  converted  at 
one  point  into  a  bulbous  enlargement  apparently  involving 
the  whole  trunk  of  the  nerve.  There  were  no  definite  ad- 
hesions and  the  nerve  was  at  no  point  divided.  After  scoring 
the  bulbous  enlargement  longitudinally,  the  nerve  was 
wrapped  in  cargile  membrane  and  restored   to  its  place. 

Improvement  began  immediately,  and  twelve  days  after 
the  operation  he  was  able  to  extend  the  wrist  somewhat, 
which  had  been  entirely  impossible  before.  This  improve- 
ment continued,  and  when  last  examined,  somewhat  over  a 
month  after  the  operation,  the  hand  could  be  extended  to 
the  horizontal  position.  Both  before  and  after  the  operation 
there  were  marked  electrical  alterations  both  to  faradism 
and  galvanism.  The  reaction  from  the  extensor  muscles 
was  slow. 


PERIPHERAL    NERVES.  49 

Diagnosis.  The  interest  of  this  case  lies  in  the  way  in  which 
the  Musculospiral  nerve  was  injured.  Inasmuch  as  no 
adhesions  were  found,  it  is  fair  to  presume  that  the  damage 
to  the  nerve  was  produced  by  the  violence  of  the  blow  crush- 
ing it  against  the  underlying  bone,  the  more  superficial 
nerves  being  spared  because  of  their  position  in  the  soft 
tissues.  This  type  of  injury  should  be  considered  in  the  case 
of  those  nerves  which  lie  in  immediate  relation  to  bone. 
The  result  of  the  operation  was  entirely  unexpected  and 
remains  difficult  to  explain  except  on  the  basis  of  improved 
nutrition  and  the  overcoming  of  certain  inhibitions  pro- 
duced by  the  swelling  of  the  nerve  as  it  lay  in  the  musculo- 
spiral groove.  The  immediate  improvement  was  unques- 
tioned and  it  is  altogether  probable  there  will  be  a  complete 
restoration  of  function. 

Prognosis.  The  outcome  of  nerve  injuries  is  in  general 
favorable.  It  is  evident  in  this  case  that  the  damage  to  the 
nerve  was  not  extreme,  and  since  improvement  began  im- 
mediately after  the  operation  it  is  fair  to  assume  that  it  will 
continue  to  complete  recovery. 

Treatment.  As  the  event  proved,  surgical  intervention 
in  this  case  was  delayed  too  long.  No  permanent  harm  was 
done  by  this  conservatism,  but  improvement  might  un- 
doubtedly have  been  hastened  had  the  operation  been  under- 
taken earlier.  It  was  delayed  on  the  supposition  that  the 
nerve  was  not  sufficiently  damaged  to  preclude  its  recovery 
without  operation. 

Note.  The  following  letter  from  the  patient,  recently  re- 
ceived, shows  the  degree  of  recovery. 

"  I  am  very  happy  to  say  that  my  recovery  is  nearly  com- 
plete and  that  I  am  sanguine  that  it  will  be  absolutely  so 
in  a  short  while.  My  forearm  is  regaining  its  former  shape 
and  size,  the  wrist-drop  has  entirely  disappeared,  and  my 
thumb  and  first  finger  are  under  almost  complete  control; 
the  other  three  fingers  are  practically  all  right.  I  am  able  to 
make  all  the  movements  required  by  my  work,  and  also 
those  of  eating,  dressing,  etc.  I  shaved  to-day  for  the  second 
time.     There  is  only  a  slight  weakness  and  lack  of  control 


50  CASE   HISTORIES    IN    NEUROLOGY. 

in  performing  a  few  things,  such,  for  instance,  as  operating  a 
typewriter  or  playing  a  piano.  I  am  writing  this  letter  with 
my  affected  hand.  The  sensation  of  touch  is  not  quite  normal 
on  the  back  of  my  thumb  yet." 


PERIPHERAL    NERVES.  5I 

Case  17.  H.,  a  man  of  sixty-four,  a  butcher  by  occupation, 
the  father  of  twelve  children,  had  been  well  up  to  three  weeks 
before  being  seen.  He  woke  one  night  with  a  feeling  of  "  dead- 
ness  "  of  the  left  hand.  This  condition  had  been  gradually 
growing  worse;  he  had  had  no  sharp  pain,  but  there  was 
distinct  weakness  and  difficulty  in  closing  the  hand.  He 
drank  beer  occasionally,  but  very  little  whiskey,  and  had  not 
been  drinking  in  excess  at  that  time.  In  general,  he  was 
physically  well. 

Examination  showed  the  ulnar  and  musculospiral  nerves 
intact.  The  median  nerve  was  involved,  as  shown  by  the 
fact  that  the  hand  grasp  was  weak  and  Imperfect,  that  the 
approximation  of  the  little  finger  and  thumb  was  not  possible. 
There  was,  however,  no  visible  atrophy  nor  objective  dis- 
order of  sensation.  Electrical  examination  gave  no  response 
to  very  strong  faradic  currents  from  the  small  muscles  of  the 
thumb.  The  galvanic  current  gave  a  slight  contraction,  slow 
in  character,  the  AnC  being  greater  than  the  CaC  (complete 
R.  D.).  The  flexors  of  the  forearm  were  normal  to  both 
currents.  Wrist  jerks  were  not  obtained  on  either  side. 
The  pupils  and  knee  jerks  were  normal.  The  pulse  was  88, 
and  the  heart  not  affected.  Except  for  a  low  specific  gravity, 
1013,  the  urine  presented  no  abnormality.  About  eight 
months  later  It  was  learned  that  recovery  had  been  complete. 

Diagnosis.  Such  an  Involvement  of  an  individual  nerve 
is  not  exceptional,  although  there  is  usually  a  more  definite 
etiology  than  was  obtained  in  this  case.  The  blood  pressure 
was  not  taken,  but  It  Is  possible  that  circulatory  disturbances 
may  account  for  such  temporary  paralyses  In  persons  of  the 
age  of  this  patient.  Alcohol  was  not  a  factor.  Pressure 
paralysis,  due  indirectly  to  alcohol,  almost  Invariably  for 
mechanical  reasons  affects  the  musculospiral  nerve.  We 
are  hardly  justified  in  terming  such  a  condition  a  neuritis 
since  signs  of  an  Inflammation  were  conspicuously  absent. 
It  is  noticeable  also  that  motion  was  very  much  more  affected 
than  sensation,  again  a  not  unusual  experience  In  slight 
paralyses.  The  complete  recovery  of  the  patient  shows  that 
the  cause  was  a  transient  one  and  presumably  not  due  to  his 
constitutional    condition.       Inasmuch    as    the    three    chief 


^2  CASE    HISTORIES    IX    NEUROLOGY. 

ner\-es  of  the  lower  arm,  the  median,  ulnar  and  musculo- 
spiral,  supply  in  a  general  way  respectively  the  flexors  of 
the  fingers,  the  interossei  and  most  of  the  small  muscles  of 
the  hand  and  the  extensors  of  the  wrist  and  hand,  simple 
tests  may  quickly  be  made  as  follows:  If  the  hand  grasp  be 
deficient  in  strength  the  median  is  involved;  if  abduction  and 
adduction  of  the  fingers  with  extension  of  the  terminal 
phalanges  be  lost  the  ulnar  is  involved ;  if  hyperextension 
of  the  hand  is  lost,  giving  rise  to  the  striking  condition  of 
wrist-drop,  the  musculospiral  is  involved. 

Prognosis.     Recovery  was  rapid  and  complete. 

Treatment.  Guarding  against  over-use,  rest  of  the  muscles 
involved  and  faith  in  natural  processes  of  repair  was  suffi- 
cient by  way  of  treatment. 


PERIPHERAL   NERVES.  53 

Case  i8.  I.,  a  man  of  twenty-two,  had  an  attack  of  typhoid 
fever  in  the  summer  of  1907.  He  was  very  ill  at  a  hospital 
for  ten  weeks.  Shortly  after  entering  the  hospital,  he  noticed 
numbness  of  the  two  inner  fingers  of  the  left  hand.  Three 
weeks  later  the  muscles  between  the  thumb  and  first  finger 
on  that  side  showed  particular  atrophy  although  both  hands 
were  very  thin.  When  he  recovered  from  the  fever  there  was 
persistence  of  numbness  of  the  two  outer  fingers  of  the  left 
hand  which  had  extended  down  as  far  as  the  wrist.  It  was 
most  marked  in  the  little  finger.  The  rest  of  the  hand 
appeared  to  him  normal,  as  did  the  right  hand.  The  patient 
thought  that  possibly  repeated  hypodermic  injections  in 
the  deltoid  region  of  the  left  arm  might  have  been  the  cause. 

Examination  showed  normal  cranial  nerves;  the  urine 
had  a  specific  gravity  of  1,022  with  no  albumin;  the  heart 
and  pulse  were  normal,  as  were  the  reflexes.  In  general  there 
was  no  discoverable  disorder  excepting  in  the  left  ulnar 
nerve.  Special  examination  of  this  nerve  showed  that  it  was 
not  painful  to  pressure  at  any  point.  All  the  muscles  of  the 
hand  supplied  by  it,  namely,  all  excepting  the  outer  short 
muscles  of  the  thumb  and  two  lumbricales,  were  markedly 
wasted.  Movements  were  very  weakly  possible.  Contact  was 
not  so  well  felt  on  the  affected  fingers  as  elsewhere.  The  tem- 
perature sense  was  not  altered  and  there  was  some  evidence 
of  hypersensitiveness  to  pain  stimuli.  The  electrical  examina- 
tion showed  very  slight  faradic  response  of  the  affected 
muscles.  Galvanic  stimulation  gave  in  places  a  slow  reaction 
with  the  AnC  equal  to  the  CaC.  The  reaction  of  degenera- 
tion was,  therefore,  not  wholly  complete. 

Diagnosis.  The  distribution  of  the  paralysis,  both  of 
sensation  and  motion,  sharply  confined  to  the  ulnar  dis- 
tribution justifies  the  diagnosis  of  a  local  Degenerative 
Neuritis  of  that  nerve,  presumably  associated  with  the 
attack  of  typhoid  fever  during  which  it  began.  Generalized 
post-typhoidal  neuritis  is  not  unusual.  It  is,  however,  excep- 
tional that  a  single  nerve  should  be  thus  involved. 

Prognosis.  The  course  of  the  difficulty  is  inevitably  slow 
when  so  high  a  degree  of  degeneration  of  the  nerve  exists. 
The  ultimate  outcome  is,  however,  favorable. 


54  CASE   HISTORIES    IN    NEUROLOGY. 

Treatment.  The  hand  should  be  spared  as  much  as  possible, 
particularly  in  relation  to  those  movements  which  demand 
a  special  use  of  the  muscles  supplied  by  the  ulnar  nerve.  In 
this  case  also  it  is  essential  that  the  general  nutrition  be 
restored  as  rapidly  as  possible.  The  usual  local  treatment 
by  massage,  electricity  and  bathing  is  advisable  in  such  a 
condition. 


PERIPHERAL   NERVES.  55 

Case  19.  S.,  a  man  of  twenty-four,  while  driving  an 
automobile,  through  skidding  of  the  car,  struck  a  tree,  was 
overturned  and  pinned  under  the  car  in  such  a  way  that 
great  pressure  was  exerted  over  his  thighs.  He  did  not  lose 
consciousness  for  any  length  of  time  and  noticed  at  first 
severe  pain  followed  by  a  sense  of  numbness  of  the  right 
leg.  When  rescued  at  the  end  of  an  hour  he  was  unable  to 
move. 

Examination,  however,  showed  that  there  was  no  definite 
injury  beyond  a  pressure  bruise  over  the  peroneal  nerve  on 
the  right  side  below  and  to  the  outer  side  of  the  knee.  Foot- 
drop  was  complete.  The  thigh  was  unaffected,  as  was  the 
left  leg.  A  strip  of  anesthesia  extended  from  the  outer  side 
of  the  knee  downward  and  forward  over  the  leg  to  the  great 
toe.  The  knee  jerks  were  present;  there  was  no  Babinski; 
the  plan  tars  were  both  normal  when  examined  about  six  days 
after  the  accident.  There  was  no  evidence  that  the  nerve 
was  cut,  but  improvement  under  massage  and  electricity 
has  been  exceedingly  slow,  so  that  at  the  end  of  about  two 
months  foot-drop  persists.  An  electrical  examination  bore 
out  the  supposition  of  injury  to  the  peroneal  nerve. 

Diagnosis.  Foot-drop  is  due  to  weakness  of  the  anterior 
group  of  muscles  of  the  leg,  commonly  known  as  the  Peroneal 
group.  These  muscles  are  the  tibialis  anticus,  the  peronei, 
extensor  longus  digitorum  and  extensor  proprius  hallucis. 
Owing  to  the  very  much  greater  strength  of  the  posterior 
muscles  of  the  leg,  secondary  contractures  are  liable  to  occur. 
This  should  be  guarded  against  in  the  treatment  of  foot-drop, 
by  supporting  the  foot  in  a  semi-  or  hyper-extended  position 
by  means  of  a  splint  at  least  part  of  the  time. 

Prognosis.  Recovery  from  such  conditions  is  slow,  usually 
a  matter  of  many  months. 

Treatment.  It  is  primarily  important  to  prevent  stretching 
of  the  weakened  muscles.  Massage  and  electricity  are 
desirable,  and  were  used  in  this  case,  to  assist  the  natural 
process  of  repair.  Violent  manipulation,  with  tiring  of  the 
already  weakened  muscles,  must  be  avoided. 


56  CASE   HISTORIES    IN    NEUROLOGY. 

Case  20.  T.,  an  unmarried  woman  of  thirty-nine,  occupied 
with  office  work,  about  the  middle  of  December,  1909,  suffered 
a  paralysis  of  the  right  side  of  her  face.  She  had  had  rheu- 
matism, had  worked  hard,  but  in  general  was  well.  For 
several  days,  preceding  the  paralysis  she  had  had  pain  in 
and  in  front  of  the  right  ear.  There  was  no  swelling  of  the 
drumhead  and  no  temperature.  During  twenty-four  hours 
the  paralysis  grew  rapidly  worse,  and  at  the  end  of  that  time 
attained  its  maximum.  There  was  no  history  of  undue 
exposure,  and  no  definite  pain  beyond  that  in  and  about  the 
ear.  When  seen,  January  5,  1910,  hearing  was  normal  in 
both  ears.  There  was  complete  palsy  of  the  right  side  of  the 
face,  all  branches  of  the  seventh  nerve  being  involved.  Taste 
was  slightly  affected  on  the  paralyzed  side  of  the  tongue. 
There  was  very  slight  faradic  response  to  the  muscles.  The 
galvanic  response  gave  active  but  slow  response  from  both 
poles,  which  were  about  equal.  The  reactions  on  the  affected 
side,  both  to  the  anode  and  cathode,  were  greater  than  on  the 
normal  side.  Indirect  stimulation  through  the  nerve  gave  a 
possible  very  slight  response  from  the  muscles.  The  reaction 
of  degeneration  was,  therefore,  partial.  In  other  respects 
the  patient  showed  no  abnormality.  Her  improvement  was 
uninterrupted. 

Diagnosis.  This  is  a  typical  case  of  so-called  Bell's  palsy, 
involving  the  whole  right  facial  nerve.  Inasmuch  as  there 
was  some  disturbance  of  taste,  the  lesion  is  to  be  located 
between  the  geniculate  ganglion  and  the  point  at  which  the 
chorda  tympani  is  given  off  from  the  facial  nerve.  The  fact 
that  all  three  branches  of  the  nerve  were  equally  involved 
places  the  disturbance  in  the  peripheral  nerve  rather  than 
in  the  central  neurones  connecting  the  cortex  with  the  facial 
nucleus  in  the  pons.  Preliminary  pain  in  the  mastoid  region 
or  in  and  about  the  ear  is  a  common  precursor  of  facial 
paralysis,  possibly  due  to  the  involvement  of  the  pars  inter- 
media in  the  process. 

Prognosis.  The  prognosis  in  such  cases  is  good,  even  if 
a  complete  reaction  of  degeneration  develops.  Recovery 
is  slow,  however,  and  may  leave  certain  secondary  defects 
of   the  nature  of   contractures  and   spasmodic   movements. 


PERIPHERAL   NERVES.  57 

The  electrical  reactions  are    the    most  valuable    means    of 
determining  the  outcome  and  the  rapidity  of  recovery. 

Treatment.  Strychnia  by  the  mouth  or  subcutaneously, 
gentle  massage  of  the  affected  muscles,  and  electricity  are 
the  best  means  of  treatment  In  such  a  case.  If  the  muscles 
respond  to  faradism  this  variety  of  current  should  be  used ; 
if  not,  the  galvanic  current,  with  preference  for  that  pole 
which  gives  the  better  reaction.  Electricity  should  be  dis- 
continued when  voluntary  power  returns,  especially  if 
associated  with  spasm. 


58  CASE    HISTORIES    IN    NEUROLOGY. 

Case  21.  O.,  a  man  of  forty- three,  was  thrown,  in  the 
summer  of  1908,  from  an  automobile,  striking  on  his  left 
shoulder,  as  the  result  of  a  collision.  He  was  at  first  un- 
conscious but  was  later  able  to  walk.  His  left  clavicle  was 
fractured  and  he  was  at  once  deaf  on  the  left  side.  There 
was  bleeding  from  the  ear  that  night  and  the  following 
morning,  whether  or  not  mixed  with  cerebrospinal  fluid 
is  not  known.  He  did  not  suffer  much  pain.  The  accident 
was  on  a  Saturday.  The  following  Thursday  or  Friday  he 
first  noticed  "  stiffness  "  of  the  muscles  of  the  face.  This 
came  on  gradually  and  had  improved  somewhat.  He  re- 
mained in  bed  for  nine  days  without  headache,  but  blowing 
his  nose  was  painful.  The  ear  ceased  to  discharge.  There 
was  a  painful  point  at  the  articulation  of  the  jaw. 

Examination  sixteen  days  after  the  accident  gave  the 
following  conditions:  The  pupils  were  normal  in  light  and 
accommodative  reflexes  and  the  visual  fields  were  not  re- 
stricted. Hearing  was  much  diminished  on  the  left,  both  by 
air  and  bone,  A  watch  placed  almost  if  not  against  the  ear 
could  be  heard,  but  not  at  a  greater  distance.  The  left  ear 
drum  was  ruptured.  There  was  incomplete  paralysis  of  the 
left  facial  nerve.  The  eye  could  be  nearly  closed;  whistling 
and  movements  of  the  left  side  of  the  face  were  difficult. 
There  was  a  quantitative  diminution  both  to  faradic  and 
galvanic  stimulation  from  nerve  and  muscles.  The  CaC 
was  greater  than  the  AnC  and  the  response  was  quick. 
There  was,  therefore,  no  R.  D.  Taste  was  possibly  slightly 
affected  on  the  left  side.  Otherwise  there  were  no  cranial 
nerv'-e  involvements  and  the  patient  in  general  was  in  good 
condition. 

When  seen  again,  six  and  a  half  months  later,  the  history 
given  was  that  the  improvement  continued  without  inter- 
ruption and  that  the  paralysis  of  the  face  had  given  place  to  a 
twitching  of  the  same  muscles.  The  deformity  of  the  face 
resulting  from  paralysis  had  subsided  in  about  three  months. 
His  hearing,  he  thought,  had  also  improved.  This  latter 
supposition  was  justified  by  an  examination  which  showed 
fair  air  and  bone  conduction,  in  marked  contrast  to  the 
condition  at  the  first  examination.     Electrical  examination 


PERIPHERAL    NERVES.  59 

of  the  affected  nerve  showed  normal  reactions.  There  was 
also  slight  spasm  in  the  facial  muscles  of  the  left  side. 

Diagnosis.  This  patient  undoubtedly  suffered  a  slight 
Basal  Fracture  extending,  as  is  usual,  through  the  temporal 
bone  in  such  a  way  as  to  involve  the  internal  and  middle  ear. 
The  rupture  of  the  ear  drum  is  a  natural  consequence  of  a 
violent  blow  on  the  side  of  the  head.  Consequent  upon  the 
original  injury  the  left  Facial  nerve  was  damaged,  presumably 
by  hemorrhage  in  its  course  through  the  middle  ear.  Facial 
paralysis,  often  of  a  severe  type,  is  a  common  result  of  fracture 
of  the  base. 

Prognosis.  The  function  of  the  facial  nerve  was  in  this 
case  entirely  restored  within  four  months.  The  extent  of 
improvement  naturally  depends  upon  the  degree  of  primary 
injury.    The  tendency  is  always  toward  recovery. 

Treatment.  No  treatment  was  necessary  in  this  case. 
When  the  conditions  within  the  ear  were  adjusted  through 
the  absorption  of  exudate  and  hemorrhage,  the  nerve  re- 
gained its  function.  There  is  no  available  treatment  for  the 
secondary  spasm,  often  an  exceedingly  troublesome  outcome 
of  facial  paralysis.  In  this  case,  the  spasm  was  so  slight  in 
degree  that  it  is  not  likely  to  give  rise  to  any  considerable 
annoyance  in  the  future. 


60  CASE    HISTORIES    IN    NEUROLOGY. 

Case  22.  R.,  a  teacher  of  twenty-nine,  except  for  the 
fatigue  incident  to  her  work,  had  been  well  up  to  July,  1906. 
At  that  time  she  suffered  from  general  pain  and  sense  of 
soreness,  but  had  no  definite  rheumatic  attack.  She  was  also 
worried  about  her  sister,  who  was  at  a  hospital.  Her  sleep 
was  poor,  she  was  tired  at  night,  had  pain  in  the  back  and 
neck;  at  times  her  whole  back  felt  tender,  but  in  spite  of  her 
discomforts  she  continued  her  teaching.  Two  weeks  before 
being  seen  she  noticed  in  the  evening,  after  a  hard  day,  that 
her  face  was  suddenly  drawn  to  one  side.  She  had  no  pain 
in  connection  with  this  paralysis.  Several  days  before,  she 
had  been  particularly  exposed  to  cold,  but  she  was  not  con- 
scious of  any  exposure  immediately  before  the  paralysis 
came  on.  The  morning  following,  the  paralysis  was  complete, 
and  with  it  there  was  considerable  pain  in  the  distribution 
of  the  right  facial  ner\'e,  together  with  the  previous  pain  at 
the  back  of  the  head  and  neck.  There  was  no  history  of  ear 
suppuration  and  she  had  not  observed  any  disorder  of  taste. 

Examination  showed  a  practically  complete  right  facial 
paralysis.  She  was  unable  to  close  her  eye  and  the  lower 
muscles  were  also  beyond  her  control.  There  was  no  pain  on 
pressure  over  'the  facial  nerv^e,  but  the  face  had  a  swollen 
appearance  and,  as  stated  above,  there  had  been  much 
complaint  of  pain  at  night,  which  had  interfered  with  her 
sleep.  On  the  anterior  two  thirds  of  the  tongue  of  the 
affected  side  sweet  and  salt  could  not  be  distinguished, 
whereas  they  were  easily  recognized  on  the  normal  side. 
Electrical  examination  showed  a  partial  R.  D.  There  was 
slight  faradic  response  from  the  affected  nerv^e  and  muscles; 
a  slow  galvanic  response,  with  the  positive  pole  equal  or 
predominating  over  the  negative  pole.  The  hearing  was 
normal  and  there  was  no  ear  suppuration.  In  other  respects 
the  patient  showed  no  significant  abnormality. 

Diagnosis.  This  is  an  instance  of  Facial  Paralysis  of 
the  so-called  peripheral  type  in  which  the  involvement  of 
the  nerv'e  extends  inward  as  far  as  or  possibly  including  the 
geniculate  ganglion.  Taste  in  the  anterior  two  thirds  of  the 
tongue  is  supplied  presumably  through  the  chorda  tympani 
nerv^e,  which  runs  with  the  facial  ner^^e  in  its  passage  through 


PERIPHERAL    NERVES.  6l 

the  middle  ear,  later  leaving  that  nerve  to  pass  with  the 
lingual  of  the  fifth  to  its  destination  in  the  tongue.  The 
involvement  of  taste  is  practically  valuable  from  a  diagnostic 
standpoint  In  that  It  determines  the  location  of  the  lesion 
between  the  geniculate  ganglion  and  the  exit  of  the  nerve 
from  the  skull.  A  lesion  of  the  facial  nerve  proximal  to  the 
geniculate  ganglion  does  not  Involve  taste  fibers. 

Prognosis.    The  prognosis  In  this  case  Is  entirely  favorable. 

Treatment.  Inasmuch  as  reaction  of  degeneration  was 
not  completely  established,  treatment  of  the  nerve  by  a 
faradic  current  was  indicated.  In  view  of  the  general  de- 
bilitated condition  of  the  patient  a  respite  from  work  was 
desirable. 

The  symptomatology  of  affections  mainly  involving  the 
peripheral  nerves  is  sufficiently  Indicated  in  the  cases  given 
in  detail  above.  The  etiology  of  such  affections  Is  particu- 
larly Important  to  determine  because  of  their  almost  uni- 
formly good  prognosis  if  the  exciting  cause  can  be  removed. 
Injuries  to  nerves  and  new  growths  (neurofibromata)  or 
other  tumors  in  the  immediate  neighborhood  of  nerve  trunks 
are  usually  easy  of  determination.  Slowly  acting  poisons, 
such  as  alcohol,  lead  or  arsenic,  may  usually  be  recognized 
if  their  great  importance  in  the  production  of  generalized 
neuritis  be  borne  in  mind.  The  simulation  of  cord  or  cere- 
bral lesions  is,  however,  often  so  close  that  errors  may  readily 
be  made,  as,  for  example,  the  misinterpretation  of  a  psychosis 
due  to  lead,  or  the  simulation  of  tabes  by  an  alcoholic  neuritis 
(see  Case  2).  Infections  of  various  sorts  are  frequently  the 
precursors  of  peripheral  affections,  as,  for  example,  neuritis 
following  typhoid  or  diphtheria,  or  in  association  with  polio- 
myelitis. In  many  cases,  however,  no  definite  etiology  is 
obtainable,  and  the  assumption  must  be  made  that  neuritis, 
often  of  a  degenerative  type,  occurs  in  cachexias  of  various 
sorts,  e.  g.,  in  tuberculosis,  cancer  or  less  definite  conditions. 
In  general,  it  may  be  said  that  the  peripheral  ner\^es  are 
extremely  prone  to  disease,  but  also  show  a  very  marked 
capacity  for  recovery.  Treatment,  therefore,  apart  from 
surgical    interference, — suturing    and    repair    of    injury    in 


62  CASE    HISTORIES    IN    NEUROLOGY. 

general, —  consists  very  largely  in  assisting  a  natural  tendency 
to  recovery.  Such  assistance  may  be  given  in  the  first  place 
by  removal  of  the  cause,  —  alcohol,  lead  or  a  generally  de- 
praved physical  condition;  in  the  second  place,  to  slight 
degree  by  drugs,  notably  strychnia,  and  effectually  by  iodide 
and  mercury,  when  syphilis  is  a  factor;  and  in  the  third 
place  by  mechanical  measures,  in  which  massage,  electricity, 
hydrotherapy  and  carefully  regulated  exercises  play  the  most 
important  part.  Massage  helps  by  maintaining  circulation, 
assisting  atrophied  muscles  and  overcoming  a  tendency  to 
contractures  with  resulting  deformities.  Electricity  is  of  far 
less  service,  but  senses  to  stimulate  muscles  no  longer  under 
control  of  the  will  and  thereby  in  some  measure  at  least  to 
preserve  and  restore  normal  function.  Hydrotherapy  is 
useful  as  a  general  tonic  measure,  and  exercises  designed  to 
restore  normal  muscular  tone  are  of  distinct  value.  None  of 
these  measures  should  be  applied  during  the  active  inflamma- 
tory stage,  except  with  the  greatest  caution  and  reserve. 


SECTION  11. 


EQUILIBRIUM 

t 

DIRECTCEREBELLAR  TRACT 


■  CONTACT 

-  EQUILIBRIUM 

-PAIN  «—  TEMPERATURE 


SPINAL  CORD. 

The  cord  is  essentially  a  concentrated  conducting  mechan- 
ism between  the  widespread  nerve  distribution  of  the  periph- 
ery and  the  brain.  On  the  motor  side  neurones  originate 
in  its  ventral  horns,  the  axones  of  which  pass  outward  to  the 
muscles;  on  the  sensory  side  the  cell  bodies  constitute  the 
dorsal  ganglia  from  which  axones  pass  into  the  cord  and  to 
the  periphery.  The  course  of  the  main  sensory  fibers  within 
the  cord  is  shown  by  the  accompanying  diagram.  It  will  be 
seen  that  the  fibers 
subserving  pain  and 
temperature  cross 
soon  after  entering 
the  cord,  whereas  temperature 
those  subserving 
contact  and  joint 
sensibility  presum- 
ably in  great  part 
pass  upward  in  the 
dorsal  columns  un- 
crossed as  far  as  the  oblongata.  All  the  sensory  tracts  ulti- 
mately reach  the  parietal  region  of  the  brain   by  way  of  the 

fillet  and  the  thalami. 

COLUMN  GOLL --pi  .  j_  j_  „ 

'  I  he  motor  tracts  are 

constituted  by  two 
neurones:  One  from 
the  pre-Rolandic  cor- 
tex through  the 
anterior  portion  of 
the  posterior  limb  of 
the  capsule,  thence 
through  the  pes  pe- 
dunculi,  pons  and 
largely  crossing  in  the  oblongata  to  constitute  the  pyramidal 
tracts  of  the  cord,  thus  becoming  associated  with  the  primary 

63      . 


Fig.  g. 


Fig. 


64  CASE    HISTORIES    IN    NEUROLOGY. 

motor  neurones  from  the  ventral  horns  to  the  muscles  (see 
Fig.  2).  In  a  cross  section  of  the  cord  these  \-arious  tracts 
appear  as  shown  in  Fig.  10. 

In  studying  affections  of  the  cord  it  is  essential  to  bear  in 
mind  that  the  dorsal  columns  are  sensory,  the  lateral  pyra- 
midal tracts  motor,  and  the  ventral  horns  motor,  with 
trophic  relations  to  the  muscles  (see  earlier  discussion, 
p.  18). 

A  peculiarity  of  a  group  of  spinal  cord  diseases  is  their 
systemic  character,  by  which  is  meant  that  certain  neurone 
tracts  show  a  distinct  tendency  to  individual  degeneration. 
Examples  are  tabes,  amyotrophic  lateral  sclerosis  and  simple 
spinal  progressive  muscular  atrophy.  A  less-marked  tendency 
to  such  systemic  degeneration  is  shown  in  the  combined 
neurone  diseases  of  the  ataxic  paraplegic  type.  Still  other 
affections  show  no  tendency  whatever  to  such  tract  limita- 
tions, as,  for  example,  multiple  sclerosis,  myelitis.  From  a 
pathological  standpoint  lesions  of  the  cord  are  inflammatory, 
—  myelitis,  poliomyelitis;  degenerative,  —  tabes,  progressive 
muscular  atrophy;  proliferative,  —  gliosis,  syringomyelia;  de- 
structive, —  new  growth,  pressure  from  without,  Pott's 
disease;  or  the  result  of  trauma,  crush  and  softening  from 
external  violence.  Examples  of  these  varied  conditions  are 
given  in  the  following  cases: 

Case  23.  I.,  six  years  old,  was  well  up  to  July  22,  1909. 
He  had  been  riding  a  bicycle  vigorously  and  had  had  a  fall 
ten  days  before,  striking  his  head,  but  leaving  no  after-effects. 
There  was  no  definite  indiscretion  in  diet.  He  had  never 
been  very  well  nourished.  Some  months  before  he  had 
suffered  from  nasal  catarrh  and  had  had  his  tonsils  removed. 
On  July  27,  he  had  fever  and  vomited.  On  July  28,  the 
temperature  was  101.4°  in  the  axilla;  the  pulse,  140.  He 
continued  to  vomit,  but  otherwise  did  not  appear  ill.  The 
following  day  there  was  some  muscular  twitching  and  slight 
discomfort  in  swallowing.  The  temperature  persisted  but 
did  not  go  above  102°  in  the  axilla.  On  August  i ,  the  tempera- 
ture became  subnormal.  The  following  day  there  was 
complete  paralysis  of  both  legs,  but  none  of  the  arms.    There 


SPINAL   CORD.  65 

was  some  pain  in  the  back,  no  rigidity  of  the  neck  muscles 
and  no  stupor.  At  the  onset  of  the  illness  he  was  slightly 
delirious  but  not  subsequently. 

Examination  showed  normal  pupils;  no  involvement  of  the 
cranial  nerves;  the  tongue  slightly  coated.  The  right  arm 
was  entirely  normal;  there  was  some  pain  on  deep  pressure 
over  the  nerves  of  the  left  arm,  also  on  raising  the  arm  over 
the  head.  The  left  leg  was  completely  paralyzed;  on  the 
right  there  were  merely  slight  movements  of  the  toes.  The 
knee  jerks  were  absent  and  no  plantar  reflexes  were  obtained. 
Sensation  was  unaffected  except  for  pain  on  pressure  over  the 
nerve  trunks,  especially  in  the  popliteal  spaces  and  in  the 
calves.  Complete  forcible  extension  of  the  legs  was  difficult 
on  account  of  the  pain.  The  heart  showed  no  abnormality 
and  the  urine  was  normal.  A  later  examination  showed 
very  marked  improvement  but  persistent  weakness  of  the 
back  muscles,  the  muscles  of  the  thighs  and  the  anterior  leg 
muscles.  It  was  possible  for  him  to  balance  himself  with 
support.  Improvement  with  orthopedic  appliances,  massage 
and  exercises  has  continued  up  to  this  time,  March,  191 1. 
He  is  now  able  to  walk  to  a  certain  extent  with  apparatus. 

Diagnosis.  The  history  of  this  case  is  typically  that  of 
Acute  Anterior  Poliomyelitis.  An  unexplained  rise  of  tempera- 
ture for  several  days  together  with  gastro-intestinal  disorder 
followed  by  flaccid  paralysis  of  one  or  all  extremities, 
is  always  strongly  indicative  of  poliomyelitis.  If  this  paraly- 
sis is  followed  by  atrophy  with  altered  electrical  reactions, 
but  still  with  a  tendency  toward  recovery,  the  diagnosis  is 
still  further  substantiated.  In  the  foregoing  case  these 
conditions  were  all  present  and  there  is  no  possibility  of 
mistaking  the  signs  for  any  other  disorder  of  the  central 
nervous  system. 

Prognosis.  The  prognosis  in  this  case  is  perfectly  good  as 
regards  life.  The  patient  was  at  no  time  in  the  slightest 
danger.  As  regards  usefulness  of  the  limbs,  the  prospects 
are  for  partial  recovery,  with,  however,  a  considerab  e  per- 
manent disability. 

Treatment.  After  the  first  week  or  ten  days,  the  treat- 
ment was  massage,   passive   and,  so  far  as  possible,  active 


66  CASE   HISTORIES    IN    NEUROLOGY. 

movements  of  the  affected  limbs;  later,  when  the  prospect 
of  the  recovery  of  muscles  grew  less,  the  application  of 
supportive  orthopedic  appliances  for  the  back  and  fixation 
of  the  joints. 


SPINAL   CORD.  67 

Case  24.  E.,  twenty-four  years  old,  in  the  latter  part  of 
August,  1906,  was  attacked  by  diarrhea  and  bowel  pain, 
with  loss  of  energy  and  disturbed  sleep,  but  at  first  without 
headache.  He  improved  and  at  the  end  of  three  days  re- 
turned to  his  work,  but  was  again  obliged  to  desist  because 
of  sudden  onset  of  back  pain,  with  retraction  of  the  head. 
There  was  still  no  headache,  although  his  head  continued 
to  be  drawn  back.  Six  days  after  the  onset  of  the  illness  he 
went  to  a  hospital,  and  was  at  once  put  to  bed.  He  was 
stuporous  for  two  or  three  days  and  had  a  temperature 
which  did  not  go  above  101°.  Examination  on  entrance 
showed  a  moderate  degree  of  prostration,  a  flushed  face, 
rigid  neck  with  slight  retraction  of  the  head,  active  knee 
jerks  and  skin  reflexes,  with  a  Kernig  sign  on  the  left.  After 
admission,  when  the  temperature  had  fallen  to  normal, 
paralysis  of  the  right  arm  and  leg  developed,  with  slight 
involvement  of  the  right  face.  There  was  also  diplopia,  and 
double  Kernig  sign  was  noted.  Five  days  later  the  neck  was 
less  stiff,  he  was  conscious  and  rational  and  complained  of 
pain  in  the  back  and  legs.  At  the  end  of  eight  days,  he  was 
able  to  move  the  right  arm  slightly,  and  the  neck  spasm  was 
decidedly  less.  Dark  red  pin-point  spots,  some  hemorrhagic 
in  character,  developed  over  the  abdomen,  chest  and  arms. 
Tenderness  over  the  nerves  of  the  right  side  subsided  in 
about  thirty  days  and  sensation  was  not  otherwise  affected. 
Improvement  in  the  paralysis  was  steady,  the  arm  gaining 
strength  at  first  more  rapidly  than  the  leg.  The  urine  was 
normal  and  micturition  unaffected,  except  on  the  first  day. 
The  white  count  was  16,000;    the  Widal  reaction,  negative. 

A  diagnosis  of  meningitis  was  made  at  the  hospital,  and 
was  not  changed  at  the  time  of  his  discharge,  forty  days 
after  entrance. 

When  seen  a  year  or  more  after,  there  was  general  atrophy 
of  the  right  shoulder-girdle  muscles,  upper  arm,  forearm 
and  hand.  The  right  leg  was  similarly  atrophied;  he  was 
unable  to  extend  the  toes.  Elbow  and  wrist  reflexes  were 
well  marked  on  the  left  and  lacking  on  the  right.  The  ab- 
dominal, epigastric  and  cremaster  reflexes  were  present  and 
equal  on  each  side.     The  knee  jerk  and  Achilles  reflex  were 


68  CASE   HISTORIES    IN    NEUROLOGY. 

not  obtained  on  the  right,  and  the  plantar  reflex  was  less 
marked  than  on  the  left.  Sensation,  including  musculer 
sensibility,  was  everywhere  normal  and  there  was  no  tender- 
ness over  nerve  trunks.  The  cranial  nerv^es  showed  no 
abnormality.  Remarkable  improvement  followed  treatment 
in   this  case. 

Diagnosis.  The  foregoing  case  is  an  excellent  example  of 
the  [Meningeal  Type  of  Poliomyelitis.  So  conspicuous  were 
the  meningeal  symptoms  during  his  residence  at  the  hospital 
that  the  error  in  diagnosis  was  not  corrected  even  after  an 
obser^^ation  extending  over  forty  days.  Had  a  lumbar 
puncture  been  made,  this  error  could  hardly  have  occurred, 
since,  particularly  in  a  meningitis  involving  the  cord, 
evidence  of  the  inflammation  would  doubtless  have  appeared 
in  the  cerebrospinal  fluid.  The  rigid  neck,  transient  stupor,  and 
Kernig  sign  are  not  enough  to  establish  a  diagnosis  of  meningi- 
tis. These  signs  are  all  of  frequent  occurrence  in  poliomyelitis, 
but  the  development  of  an  extensive,  flaccid  paralysis  should 
have  rendered  the  diagnosis  practically  certain.  It  is  not  to 
be  doubted  that  many  such  csaes  in  the  past  have  been 
erroneously  diagnosticated  as  primary  meningitis.  A  further 
fact  worthy  of  mention  in  this  case  is  that,  after  apparent 
recovery  and  return  to  work,  symptoms  again  developed, 
leading  on  the  sixth  day  to  paralysis  of  the  unusual  hemiplegic 
type. 

Prognosis.  The  outcome  in  this  case  has  been  a  practical 
restoration  of  function.  In  general  the  prognosis  of  the 
"  meningeal  "  and  "  peripheral  "  types  is  better  than  of  the 
spinal  type. 

Treatment.  Mechanical  methods  of  treatment  undoubt- 
edly assisted  greatly  in  bringing  about  the  favorable  result. 


SPINAL   CORD.  69 

Case  25.  S.,  a  girl  of  twelve,  previously  well,  as  it  was 
supposed  "  caught  cold."  The  following  morning  her  throat 
was  painful  and  there  was  pain  in  the  muscles  of  the  neck. 
Diphtheria  and,  later,  typhoid  fever  were  considered,  and 
tonsillitis  was  diagnosticated.  She  was  in  bed  for  about  two 
weeks  with  fever  as  high  as  103.5°.  The  neck  was  swollen, 
particularly  on  the  right  side.  She  complained  also  of  pain 
in  one  of  her  legs.  About  two  weeks  after  the  onset,  on 
attempting  to  go  down  stairs,  she  found  that  she  was  prac- 
tically unable  to  walk  on  account  of  leg  weakness.  She  had 
then  also  an  internal  strabismus.  She  recovered  from  the 
fever  and  at  no  time  complained  of  headache  or  other  pain 
excepting  in  the  neck,  which  felt  stiff.  She  vomited  somewhat 
during  the  preliminary  illness.  The  weakness  in  the  legs 
presumably  came  on  while  she  was  ill  in  bed  and  the  exact 
time  of  its  onset  cannot,  therefore,  be  determined.  The 
pain  in  the  neck  passed  ofif  in  about  a  week.  She  also  had 
pain  in  both  thighs,  then  in  the  legs.  The  arms  remained 
normal.     Diplopia  was  observed  at  the  end  of  about  a  week. 

She  recovered  so  far  as  her  general  condition  was  con- 
cerned, but  with  the  following  defects  evident  on  examination, 
four  months  after  the  acute  attack.  Smell  was  unimpaired, 
the  eye  grounds  were  normal,  there  was  paresis  of  the  left 
external  rectus,  with  diplopia  on  looking  directly  forward 
and  toward  the  left.  The  position  of  the  two  images  was  not 
parallel.  The  facial  nerves  were  not  involved,  although 
there  was  a  possible  slight  asymmetry  of  the  face.  In  chew- 
ing, food  collected  in  the  cheeks  but  about  equally  on  the 
two  sides,  apparently  due  to  involvement  of  the  fifth  rather 
than  the  seventh  nerves.  The  mouth  was  opened  imperfectly 
with  a  maximum  aperture  between  the  teeth  of  five  eighths 
of  an  inch,  and  the  lower  jaw  sagged  toward  the  left.  Lateral 
movements  were  also  imperfect,  the  jaw  moving  considerably 
better  toward  the  right  than  toward  the  left.  There  was  gen- 
eral weakness  of  the  muscles  supplied  by  the  fifth  ner\'e, 
probably  on  both  sides.  The  hearing  was  normal ;  the  tongue 
was  protruded  markedly  toward  the  left,  and  was  soft  and 
atrophied  on  the  left  side.  The  uvula  sagged  somewhat  to 
the    right    and    was    flaccid.      Taste    on    the    anterior    two- 


70  CASE    HISTORIES    IN    NEUROLOGY. 

thirds  of  the  tongue  was  unaffected  on  either  side.  There 
was  a  distinctly  nasal  voice,  but  with  no  aphonia.  Difficulty 
in  swallowing  was  marked.  The  arms  were  normal;  the 
heart  negative  with  a  pulse  of  120;  the  legs  were  weak,  the 
left  much  more  so  than  the  right.  It  was  difficult  to  rise 
from  a  chair;  the  gait  was  unsteady,  with  a  strong  tendency 
to  fall.  The  left  foot  was  turned  outvvard  and  pronated,  and 
the  muscles  were  weak.  The  knee  jerks  were  more  active 
on  the  right  than  on  the  left.  There  was  no  Babinski;  the 
Achilles  jerks  were  present,  and  sensation  was  unimpaired. 
Seen  again  about  three  weeks  later  there  was  general  im- 
provement in  walking,  in  the  capacity  to  open  the  mouth, 
in  speech  and  in  the  paresis  of  the  uvula.  She  still  had 
diplopia  and  very  marked  atrophy  of  the  tongue,  with  diiift- 
culty  in  swallowing.  This  improvement  continued,  but 
when  last  seen  the  defects  mentioned  above  were  still  per- 
sistent, although  not  so  troublesome,  in  part  because  she  had 
become  more  accustomed   to   their  presence. 

Diagnosis.  This  case  escaped  diagnosis  at  the  hands  of  her 
physician,  because  of  its  resemblance  to  meningitis  or  to 
typhoid  fever.  The  subsequent  course  of  the  disease  with 
persistence  of  definite  muscular  weakness  shows  it  undoubt- 
edly to  have  been  Poliomyelitis  or,  more  strictly  speaking, 
a  Poliencephalomyelitis  involving  various  cranial  nerves 
as  well  as  the  legs.  The  points  of  special  interest  in  this  as 
in  other  cases  of  poliomyelitis  are:  The  insidious  onset  of 
the  disease  and  the  difficulty  at  the  outset  of  making  an 
exact  diagnosis;  the  predominant  involvement  of  cranial 
nerves;  and  especially  the  unilateral  atrophy  of  the  tongue 
from  an  invasion  of  one  hypoglossal  nucleus;  the  fact  that 
these  cranial  nerve  disturbances,  although  marked  on  ex- 
amination, were  practically  unrecognized  by  the  patient; 
and  finally,  the  great  rarity  of  so  extensive  an  involvement  of 
cranial  nerves  extending  well  into  the  pons  as  shown  by  the 
paresis  of  the  fifth  and  sixth  pairs.  The  meningeal  symptoms 
with  stiffness  of  the  neck  constitute,  according  to  recent 
experience,  a  common  group  of  signs  in  the  early  stages  of  the 
disease. 

Prognosis.     The  outcome  has  been  favorable.     There  is  a 


SPINAL    CORD.  71 

possible  persistent  danger  in  the  paresis  of  the  throat  muscles, 
but  this  is  slight. 

Treatment.  There  is  no  available  treatment  for  the 
cranial  nerve  involvements.  Greater  care  should  be  observed 
in  masticating  and  swallowing  than  under  ordinary  circum- 
stances, and  such  exercises  as  are  possible  should  be  prac- 
ticed to  overcome  the  motor  defects  of  the  nerves  involved. 
The  condition  of  the  leg  improved  under  treatment  and  when 
the  patient  was  last  seen  was  a  source  of  trifling  inconvenience. 


72  CASE   HISTORIES    IN    NEUROLOGY. 

1 

Case  26.  N.,  twenty  years  old,  a  student  of  unusually 
strong  physique  and  hitherto  well,  had  been  employed  in 
out-of-door  work  during  the  early  part  of  the  summer  of 
1 910.  He  had  been  in  the  habit  of  swimming  in  fresh  water 
five  or  six  -times  a  week.  June  25,  he  had  what  he  called 
a  "  bilious  attack,"  which  was  relieved  by  castor  oil.  He 
recovered  and  returned  to  work.  August  2,  he  had  chilly 
sensations,  and  in  general  did  not  feel  well.  He  went  to  work, 
however,  the  next  day  as  usual  but  was  conscious  of  some 
stiffness  of  the  neck  with  headache.  The  following  day, 
August  4,  he  remained  at  home  and  in  bed.  His  temperature 
was  slightly  over  100°.  He  was  able  to  get  up  and  there  was 
no  paralysis.  The  stiff  neck  persisted  and  that  night  he  was 
unusually  restless.  The  next  morning,  August  5,  weakness 
of  both  arms  appeared,  much  more  marked  on  the  right. 
The  legs  were  unaffected.  During  the  day  the  paralysis 
increased;  some  difficulty  in  speech  developed,  associated 
with  an  extreme  degree  of  apprehensiveness.  In  general 
his  mental  state  seemed  not  wholly  normal.  When  seen 
at  nine  on  the  evening  of  August  5,  examination  showed  the 
following  conditions: 

The  pupils  were  wide  and  responded  well  to  light.  There 
was  no  definite  paralysis  of  the  seventh  pair,  but  whistling  was 
not  easily  possible.  The  masseters  were  strong,  the  tongue 
well  protruded,  straight  and  freely  movable.  There  was  no 
aphonia  but  speech  was  difficult,  evidently  owing  to  want  of 
air.  Respiration  was  very  superficial ;  no  breath  sounds  were 
heard  over  the  right  apex.  He  yawned  continually,  com- 
plained that  the  room  was  close,  and  there  was  every  evidence 
that  he  was  suffering  from  respiratory  difficulty.  There  was 
no  movement  whatever  of  the  accessory  muscles  of  respira- 
tion; the  diaphragm  alone  was  active.  Excepting  for  slight 
movements  of  the  hand,  the  right  arm  was  paralyzed.  The 
arm  reflexes  were  lacking;  there  was  no  pain  over  the  nerve 
trunks.  The  left  arm  was  also  extremely  weak.  The  neck 
was  stiff;  the  head  could  be  moved  laterally,  but  with  diffi- 
culty directly  forward  and  backward,  and  swallowing  was 
difficult.  There  was  no  abdominal  reflex.  The  legs  showed 
no    manifest    involvement;     the    knee   jerks   were    inactive; 


SPINAL   CORD.  73 

there  was  no  clonus  or  Babinski  sign;  slight  normal  plantar 
flexion  and  well-marked  Achilles  reflexes.  The  increase 
of  respiratory  symptoms  was  rapid,  and  death  occurred  at 
3  A.M.  from  respiratory  failure,  less  than  twenty-four  hours 
after  the  onset  of  paralytic  signs.  The  heart  remained  fairly 
normal  in  action  until  near  the  end,  with  a  pulse  of  lOO  to  120. 
There  was  much  restlessness  during  the  last  hours,  with 
delirium  of  a  distressing  sort,  —  that  he  was  being  choked, 
that  there  was  a  band  about  his  neck,  —  evidently  directly 
dependent  upon  the  air  hunger. 

Diagnosis.  This  case  is  a  typical  example  of  the  rapidly 
fatal  form  of  Poliomyelitis,  and  should  not  easily  be  mistaken 
for  any  other  condition.  The  mode  of  onset,  followed  by  a 
flaccid  atrophic  paralysis,  is  perfectly  characteristic. 

Prognosis.  In  this,  as  in  practically  all  cases  of  death  from 
the  disease,  the  fatal  outcome  was  due  to  an  invasion  of  the 
upper  portion  of  the  cord,  involving  the  phrenic  nerve  (third 
and  fourth  cervical  segments)  and  the  nerve  supply  of  the 
accessory  muscles  of  respiration.  The  prognosis  as  regards 
life  is  determined  by  the  location  of  the  pathological  process 
rather  than  by  its  essential  severity. 

Treatment.  In  such  a  case  there  is  nothing  to  be  done 
beyond  rendering  the  final  hours  as  peaceful  as  possible. 
Artificial  respiration  is  certainly  not  desirable  in  a  condition 
of  so  hopeless  a  character,  associated  with  the  most  acute 
physical  and  mental  suffering. 


74  CASE   HISTORIES    IN    NEUROLOGY. 

Case  27.  E.,  a  married  man  of  twenty-seven,  of  previous 
good  health,  active  in  business,  in  general  of  good  habits, 
and  without  venereal  infection,  was  seized  on  September 
15,  1907,  with  pain  in  the  lower  back.  This  he  had  noticed 
slightly  two  days  before.  When  seen  by  his  physician  on  the 
day  following  the  severe  pain  his  temperature  was  slightly 
ele^•ated.  The  diagnosis  of  probable  lumbago  was  made. 
The  next  day,  September  17,  he  still  complained  of  pain  in 
the  back  which  extended  into  the  sciatic  nerv^es.  He  felt 
weak  and  tired  and  generally  nervous  from  loss  of  sleep  and 
pain.  On  the  morning  of  the  21st,  however,  he  was  able 
to  walk,  but  later  the  same  day  suddenly  lost  power  in  the 
right  leg  and  had  increased  pain  in  the  left  leg.  The  night 
following,  the  left  leg  was  also  paralyzed  similarly  to  the 
right  and  he  was  unable  to  pass  urine  voluntarily.  On  Sep- 
tember 22,  there  was  paralysis  of  both  legs  and  of  the  bladder 
and  rectum,  necessitating  catheterization.  The  temperature 
was  104°. 

When  seen  on  the  afternoon  of  September  22,  the  patient 
appeared  very  ill.  There  was  sordes  of  the  lips;  the  skin 
was  hot  and  dry;  the  tongue  coated.  The  pupils  were  equal 
in  size,  with  adequate  light  and  accommodative  response. 
There  were  no  paralyses  of  the  cranial  nerves.  His  mind 
was  perfectly  clear,  but  he  was  extremely  apprehensive  in 
appearance  and  manner;  tremulous,  but  not  emotional. 
The  heart,  liver  and  spleen  were  normal ;  the  pulse  somewhat 
rapid.  There  were  no  paralyses  of  the  arms,  and  sensation 
of  the  upper  extremities  was  normal.  The  breathing  was 
slightly  labored,  but  the  movements  of  the  chest  were  in 
general  good.  There  was  no  disorder  of  sensation  over  the 
body  nor  painful  points  over  the  spine.  The  abdominal 
reflexes  were  very  slight.  The  legs  showed  much  motor 
weakness  and  could  not  be  raised  from  a  horizontal  position. 
No  movements  of  the  right  foot  were  possible,  but  definite 
though  slight  contractions  of  the  muscles  both  of  the  thigh 
and  leg  could  be  made.  The  movements  of  the  toes  of  the 
left  foot  were  retained,  also  of  the  large  muscles  of  the  thigh 
and  leg,  which  were  somewhat  stronger  than  on  the  right. 
The  knee  jerks  were  very  slight  on  the  left  and  not  obtained 


SPINAL   CORD,  75 

on  the  right.  There  was  no  plantar  reflex.  There  was  definite 
front  tap  contraction  in  both  legs,  but  no  Achilles  response 
or  clonus.  Sensation  to  touch,  pain  and  temperature  was 
normal.     Sense  of  position  was  also  undisturbed. 

During  the  following  twenty-four  hours  the  paralysis 
steadily  ascended  and  the  patient  died  at  3  a.m  ,  September  24, 

In  connection  with  this  case  it  is  of  interest  that  a  child 
of  the  patient,  three  and  one-half  years  old,  had  been  well 
up  to  September  7.  He  then  was  taken  with  sudden  rise  of 
temperature  and  general  feelings  of  illness.  Supposing  his 
condition  to  be  due  to  a  condition  of  the  mouth,  the  gums 
were  lanced  and  the  temperature  diminished.  He  was 
regarded  as  recovered,  but  it  appeared,  although  the  family 
had  not  particularly  noticed  this  fact,  that  he  had  not  walked 
since.  Cursory  examination  showed  partial  paralysis  of  the 
left  arm  and  of  both  legs.  The  father,  as  stated  above,  was 
taken  ill  one  week  later. 

Diagnosis.  The  case  of  the  father  illustrates  the  virulent 
and  quickly  fatal  form  of  Poliomyelitis  of  the  ascending  type, 
undoubtedly  often  mistaken  in  the  past  for  so-called  Landry's 
Paralysis.  The  association  of  this  rapidly  fatal  case  in  an 
adult  with  that  of  a  child  of  a  far  milder  form  in  the  same 
family  is  a  matter  of  importance  in  connection  with  epidemi- 
ology. It  should  not,  however,  forthwith  be  assumed  that 
one  case  was  derived  from  the  other,  inasmuch  as  both  may 
have  been  derived  from  a  common  source.  The  fact  of  actual 
contagion  has  not  been  satisfactorily  established  in  this 
disease,  but  its  possibility  should  be  borne  in  mind  pending 
further  investigation.  It  should  be  regarded  as  definitely 
infectious  and  therefore  potentially  contagious. 

Prognosis.  The  fatality  of  poliomyelitis  depends  upon  the 
involvement  of  the  nerves  concerned  in  respiration.  A 
localized  invasion  of  the  cervical  cord  or  oblongata  is,  there- 
fore, much  more  serious  than  a  widely  extended  invasion 
of  other  portions  of  the   nervous  system. 

Treatment.    Treatment  in  this  case  was  entirely  unavailing. 

Note.  Poliomyelitis,  or,  as  it  should  more  properly  be 
called,  poliencephalomyelitis,  is   a  general   infection   of   the 


76 


CASE   HISTORIES   IN    NEUROLOGY 


nen'ous  system  due  to  a  filterable  virus  of  unknown  character. 
The  mode  of  dissemination  of  this  \irus  is  also  wholly  un- 
known beyond  the  fact  that  it  seems  probable  that  its  point 
of  entrance  is  the  nasal  mucous  membrane.  The  primary 
effect  is  a  generalized  inflammation  of  the  brain  and  spinal 
cord  membranes  associated  with  elevation  of  temperature 
and  other  signs  of  general  infection.     The  frequent  but  not 

constant  result  of 
the  infection  is  an 
invasion  of  the 
spinal  cord  and 
brain  stem  par- 
ticularly, leading 
to  destruction  of 
the  motor  ners^e 
cells  with  conse- 
quent atrophic 
paralysis,  de- 
pending upon  the 
extent  of  the  de- 
structive process. 
The  infectiousness  of  the  disease  has  been  amply  demonstrated 
experimentally;  its  contagiousness  is  still  in  doubt;  there 
is  much  evidence  to  show  that  the  virus  is  widely  prevalent 
at  certain  seasons  and  that  it  is  not  immediately  transmitted 
from  person  to  person.  The  outcome  of  the  disease  varies 
widely,  as  illustrated  by  the  preceding  cases.  In  the  prepara- 
lytic stage  and  as  a  possible  prophylactic,  urotropin  may  be 
liberally  used.  It  is  certainly  inefhcacious  after  the  paralysis 
has  developed.  The  subsequent  treatment  depends  upon 
the  nature  of  the  residual  paralysis.  In  the  natural  process 
of  recovery  of  muscular  power,  great  care  must  be  taken 
not  to  stretch  paralyzed  muscle  groups.  Much  may  be  ac- 
complished for  an  indefinite  time,  a  year  or  more,  by  assidu- 
ous massage,  exercises  and  muscle  training,  accompanied 
if  necessary  by  surgical  procedures.  Apparatus  should  be 
applied  late,  after  all  possibility  of  muscular  recovery  has 
passed.  Each  case  should  be  subjected  to  painstaking 
individual  study. 


Fig.  II.    Poliomyelitis;  Partial  Destruction  of  Ventral  Horns. 


SPINAL   CORD.  77 

Case  28.  U.,  thirty-two  years  old,  gave  as  his  chief  com- 
plaint that  he  was  unable  to  use  his  left  arm  properly  and 
that  it  had  grown  smaller.  As  a  child,  he  had  not  had  con- 
convulsions  or  children's  diseases.  At  twenty,  he  had 
gonorrhea,  followed  by  rheumatism  in  knees,  ankles  and 
wrists.  Five  and  again  two  years  ago  he  had  had  further 
attacks  of  joint  infection,  and  at  one  time  a  transient 
hematuria.  About  one  and  a  half  years  ago  it  was  noticed 
that  his  left  arm  was  thinner  than  the  right,  although  at  that 
time  this  occasioned  no  inconvenience.  Later,  the  arm  became 
noticeably  weak,  and  for  the  past  few  months  he  had  noticed 
progressive  difficulty  in  raising  the  right  arm  as  well  as  the 
left,  which  was  primarily  affected.  He  had  also  observed  that 
the  right  arm  was  growing  smaller  as  the  left  had  been  doing 
for  upwards  of  a  year  past.  For  two  or  three  weeks  he  had 
been  annoyed  with  what  he  called  "  twitching  pains," 
especially  in  the  left  arm  and  leg. 

Examination  showed  a  poorly  nourished  man  with  sallow 
skin,  pupils  slightly  irregular  but  reacting  properly  to  light 
and  distance.  There  was  no  Romberg  sign.  Hearing  was 
somewhat  impaired,  especially  on  the  left.  The  throat 
showed  nothing  abnormal.  There  were  palpable  cervical, 
axillary,  epitrochlear  and  inguinal  glands.  Over  the  chest 
many  sharp  fibrillary  muscular  contractions  of  the  pectoral 
muscles  were  noticeable,  together  with  similar  contractions 
in  the  sternomastoid,  biceps,  triceps  and  other  muscles  of 
the  upper  extremities.  The  back  showed  a  lateral  curvature 
of  the  spine,  toward  the  left  in  the  thoracic  region  and  to  the 
right  in  the  lumbar  region.  There  was  marked  atrophy  of 
the  left  serratus,  giving  rise  to  a  typical  angel-wing  scapula. 
This  was  less  marked  on  the  right.  In  certain  positions,  the 
rhomboid  major  on  the  left  was  brought  out  prominently 
as  a  muscular  band  running  from  the  middle  of  the  vertebral 
border  of  the  scapula  diagonally  in  a  median  line,  indicative 
of  atrophy  of  the  neighboring  muscles.  The  left  supra- 
spinatus  was  markedly  atrophied,  the  right  less  so;  the 
trapezii  were  fairly  preserved.  Lungs,  heart  and  abdomen 
showed  no  abnormality.  The  left  arm  at  the  last  examination 
showed  practically  a  complete  paralysis  with  extreme  atrophy 


78  CASE   HISTORIES    IN    NEUROLOGY. 

of  all  the  muscles,  including  the  deltoid.  Inward  and  outward 
rotation  were  slightly  preserved.  The  right  arm  showed 
much  less  disturbance  of  function.  Movements  could  be 
executed  with  fair  strength  with  the  exception  of  extreme 
elevation.  The  intrinsic  muscles  of  the  left  hand  were  ex- 
tremely atrophied;  of  the  right,  as  yet  normal.  Electrical 
examination  of  the  affected  muscles  showed  a  partial  reaction 
of  degeneration;  faradic  irritability  was  not  completely 
lost.     The  urine  showed  no  abnormality. 

Diagnosis.  The  essential  feature  of  this  case  is  a  progressive 
atrophy  of  the  muscles  of  the  upper  extremities,  including 
the  shoulder  girdle,  particularly  marked  on  the  left  side,  but 
now  clearly  beginning  also  on  the  right.  In  the  absence  of 
objective  sensory  disorders  which  this  patient  has  at  no  time 
shown,  and  of  other  signs  of  structural  disease,  the  diagnosis 
of  Progressive  Muscular  Atrophy  may  be  made  with  assurance. 
The  differential  diagnosis  is  not  difificult.  It  cannot  be 
mistaken  for  syringomyelia,  because  of  the  entire  absence 
of  sensory  involvement,  nor  for  peripheral  neuritis  on  account 
of  the  method  of  onset,  its  progressive  course  and  the  absence 
of  pain  on  pressure  over  the  nerve  trunks.  Degenerations 
due  to  lead  (see  Case  5)  may  lead  to  confusion,  a  matter 
determined  by  the  discovery  of  lead  in  the  excretions  and 
by  a  history  of  its  possible  ingestion.  The  spinal  type  of 
progressive  muscular  atrophy  (Aran-Duchenne)  usually  first 
manifests  itself  through  atrophy  of  the  small  muscles  of  the 
hand,  supplied  chiefly  by  the  ulnar  and  to  less  degree  by  the 
median  nerve. 

Prognosis.  This  patient  is  a  man  of  poor  physique.  The 
atrophy  has  progressed  rapidly.  It  is,  therefore,  unlikely 
that  he  will  live  more  than  three  or  four  years. 

Treatment.  The  treatment  is  directed  to  a  checking  of 
the  progressive  atrophy.  A  cure  of  the  condition  is  not  possi- 
ble, but  it  is  altogether  probable  that  its  course  may  be  in  a 
measure  stayed  by  abstention  from  the  use  of  the  muscles 
and  the  administration  of  tonic  drugs  of  which  strychnia 
is  the  best  representative.  Increasing  doses  of  strychnia 
should,  therefore,  be  given  in  the  hope  that  thereby  the  pro- 
gressive nerve  degeneration  may  be  checked. 


SPINAL   CORD.  79 

Case  29.  R.,  a  woman  of  thirty-four,  gave  a  history  of 
excellent  health  and  active  life  as  a  servant.  Except  for 
headaches  she  had  been  without  disease  of  consequence. 
Her  family  history  was  of  interest  from  the  fact  that  her 
father,  aunts  and  second  cousins  on  her  father's  side  had 
suffered  or  were  suffering  from  the  same  muscular  affection 
for  which  she  sought  advice.  So  frequently  had  the  affection 
appeared  in  members  of  the  family  that  it  had  come  to  be 
known  by  her  family  name  in  the  place  in  which  she  lived. 
The  course  of  the  disease  was,  in  general,  gradual  loss  of 
power  in  the  hands  and  arms  and  later  in  the  legs.  There 
was  said  also  to  have  been  some  sensory  disturbance. 

For  a  period  of  four  or  five  months  the  patient  had  noticed 
a  feeling  of  numbness  and  beginning  weakness  of  the  small 
muscles  of  the  left  hand.  There  was  some  difficulty  in  holding 
objects  firmly,  and  it  was  not  possible  to  extend  the  fingers 
completely.  There  was  no  involvement  of  the  left  hand  or 
of  the  legs.  Examination  showed  the  interosseous  muscles 
of  the  left  hand  markedly  atrophied  without  invasion  of 
the  forearm  muscles.  The  left  hand  was  colder  than  the 
right,  but  objectively  sensation  to  contact  and  pain  was 
entirely  unimpaired.  Electrical  examination  gave  no  faradic 
response  in  the 
small  muscles  of 
the  hand,  where- 
as galvanic  stim- 
ulation gave  a 
slow  contraction 
with  the  cathodal 
closing  contrac- 
tion equal  to  the 

anOdal      closing        Fig.    12.      from   a   case  of    Progrbssivk    muscular    Atrophy, 

contraction.  The  '"°^'''^  "^"^  "^  ventral  horn  lesion. 

knee  jerks  were  normal;  the  pupils  showed  no  abnormality; 
the  pulse  was  80;  the  radial  arteries  soft  and  the  heart 
normal. 

Diagnosis.  This  case  must  be  interpreted  as  an  unusual 
family  form  of  Progressive  Muscular  Atrophy  in  a  very  early 
stage.    The  complaint  of  sensory  disorder,  numbness  and  the 


80  CASE   HISTORIES    IN    NEUROLOGY. 

like  ia  often  made  when  no  objective  disturbance  is  dis- 
coverable. The  examination  gave  no  evidence  that  other 
elements  than  the  motor  peripheral  neurones  were  affected. 
The  evident  family  character  of  the  disease  is  also  strong 
evidence  in  favor  of  the  diagnosis  of  muscular  atrophy,  al- 
though certain  forms  of  this  disease  appear  to  be  wholly 
lacking  in  this  element  of  heredity.  Atrophy  beginning  in 
the  small  hand  muscles  is  significant  (see  Case  28). 

Prognosis.  The  affection  will  be  slowly  progressive, 
invading  successively  the  arm  and  shoulder  muscles,  later, 
possibly,  the  legs,  if  death  does  not  sooner  supervene,  as  a 
result  of  the  gradual  extension  into  the  oblongata. 

Treatment.  The  muscles,  especially  those  involved  in  the 
process,  should  be  protected  from  over-fatigue.  Too  vigorous 
treatment  by  massage  or  electricity  is  to  be  avoided.  Strych- 
nia should  be  given. 


SPINAL   CORD.  »I 

Case  30.  O.,  a  married  man  of  forty-five,  an  expressman  by 
occupation,  had  noticed  a  gradual  loss  of  power  in  the  right 
leg  for  seven  or  eight  months,  insidious  in  onset.  He  had  had 
no  injury  although  he  was  accustomed  to  carry  heavy  weights. 
At  first  he  had  slight  pain  in  the  muscles  and  nerves  of  the 
calf  and  later  over  the  instep.  This  pain  had  continued  to  a 
greater  or  less  degree.  There  was,  however,  none  above  the 
knee.  There  had  also  been  some  pain  in  the  left  leg  and  he 
had  become  apprehensive  lest  the  same  process  were  begin- 
ning in  that  leg.  The  pain  had  been  dull  and  never  lancinat- 
ing in  character.  The  right  leg  had  steadily  grown  worse, 
so  that  when  seen  he  had  marked  foot-drop  with  great  diffi- 
culty in  flexing  the  leg.  The  condition  had  been  diagnosti- 
cated as  muscular  rheumatism.  There  was  no  history  of 
other  similar  cases  in  the  family. 

The  physical  examination  showed  the  left  pupil  slightly 
larger  than  the  right,  with  a  somewhat  better  light  reaction 
on  the  right  than  on  the  left.  The  hearing  was  normal  and 
the  cranial  nerves  otherwise  free.  The  arms  showed  no 
abnormality;  the  heart  was  normal;  the  pulse,  68  and 
regular.  All  the  muscles  of  the  right  leg  were  weak  and 
reduced  in  size ;  foot-drop  was  very  marked  and  had  existed 
practically  from  the  beginning  of  the  illness.  Knee  jerk  was 
absent  on  the  right,  active  on  the  left.  No  Achilles  reflex 
was  obtained  on  either  side.  The  plantar  was  normal  on 
both  sides  and  there  was  no  clonus.  Sensibility  was  un- 
impaired, including  sense  of  position.  There  was  no  pain 
over  the  nerve  trunks.  The  right  foot  was  somewhat  cyanotic. 
The  electrical  examination  gave  no  reaction  to  a  strong 
faradic  current  in  the  muscles  of  the  right  leg,  with  normal 
reactions  on  the  left.  Galvanic  stimulation  gave  CaC  greater 
than  AnC  on  both  sides,  but  slow  in  character  and  with 
diminished   excitability  on   the  right. 

Diagnosis.  The  probable  diagnosis  in  this  case  is  Pro- 
gressive Muscular  Atrophy  of  the  Neural  Type.  It  is  to  be 
distinguished  from  a  localized  neuritis  in  the  fact  that  its 
course  is  progressively  toward  greater  atrophy  rather  than 
toward  recovery.  Pain  over  the  nerve  trunks  is  less  marked 
than  in  neuritis;    the  electrical  conditions  and  the  muscular 


82  CASE   HISTORIES    IN    NEUROLOGY. 

atrophy  may  for  a  time  at  least  be  the  same  in  the  two  con- 
ditions. This  type  of  progressive  muscular  atrophy  is  to  be 
distinguished  from  the  spinal  type  inasmuch  as  the  ventral 
horn  cells  are  not  primarily  involved,  and  that  the  disease 
throughout  bears  the  stamp  of  a  peripheral  rather  than  a 
central  type  of  degeneration.  The  fact  that  no  other  cases 
have  occurred  in  the  family  speaks,  somewhat,  against 
the  diagnosis  of  neural  atrophy. 

Prognosis.  The  prognosis  is  ultimately  bad,  although  the 
course  of  the  disease  Is  exceedingly  slow,  and  beginning,  as 
it  does,  in  the  lower  portion  of  the  body  does  not  Invade  vital 
areas  as  is  ordinarily  the  case  in  the  simple  spinal  progressive 
atrophy. 

Treatment.  Strychnia  is  indicated,  in  the  hope  of  checking 
the  progress  of  the  atrophy.  Massage  and  electricity  are 
justified  and  helpful  if  applied  In  moderation.  There  is, 
perhaps,  more  danger  of  doing  harm  than  good  by  the  indis- 
criminate use  of  either  of  these  methods  of  treatment.  Avoid- 
ance of  fatigue  must  be  Insisted  upon,  but  at  best  the  progress 
of  the  disease  may  be  hindered  and  not  completely  checked 
by  any  means  of  treatment  now  at  our  command.  The 
complete  obscurity  of  the  etiology  renders  the  treatment  still 
more  uncertain. 


SPINAL   CORD.  83 

Case  31.  L.,  an  unmarried  woman  of  nineteen,  for  five 
years  had  complained  of  weakness  of  the  arms.  Her  father 
was  said  to  have  had  the  same  weakness.  She  had  never 
been  robust  and  had  worked  hard,  particularly  of  late,  when 
she  had  noticed  special  difficulty  in  lifting  heavy  articles. 
Her  menstruation  had  been  irregular  and  painful.  She  had 
had  no  difficulty  with  her  stomach  and  had  had  no  cough. 
Her  sleep  was  satisfactory;  her  weight,  118-2-  pounds;  hemo- 
globin,  80%. 

Examination  showed  a  weak-looking  girl  with  round  shoul- 
ders and  expressionless  face.  Further  investigation  revealed 
that  there  was  marked  atrophy  of  both  deltoids,  together  with 
most  of  the  muscles  of  the  upper  arms,  chest  and  back.  The 
clavicles  were  particularly  prominent.  In  the  arms,  the 
triceps  and  biceps  on  both  sides  were  weak  and  atrophied, 
but  the  disturbance  was  more  marked  on  the  right  side.  The 
right  serratus  was  also  particularly  weak,  giving  rise  to  an 
extreme  prominence  of  the  clavicle.  The  expressionless 
character  of  the  face  was  due  to  weakness  of  both  facial  nerves, 
evidently  a  part  of  the  general  process.  The  pupils  were 
normal,  the  thyroid  slightly  enlarged;  the  reflexes  of  the  left 
arm  were  not  obtained,  but  were  weakly  present  on  the  right. 
There  was  no  atrophy  whatever  of  the  leg  muscles;  the  knee 
jerks  were  present  and  normal. 

Diagnosis.  This  patient  presented  a  condition  of  the 
muscles  evidently  not  due  to  the  ordinary  progressive  muscu- 
lar atrophy  of  the  spinal  type,  the  distribution  of  which  Is 
primarily  In  the  small  muscles  of  the  hand,  and  extending 
upward.  In  this  case,  the  weak  muscles  were  confined  to 
the  upper  part  of  the  body,  face  and  upper  arms.  The  fore- 
arms and  hands  were  conspicuously  spared.  The  case  is, 
therefore,  to  be  classified  in  the  general  category  of  the 
Muscular  Dystrophies,  rather  than  among  the  atrophies  of 
the  spinal  type.  The  lesion  differs  on  the  pathological  side 
in  the  fact  that  the  degeneration  of  the  muscles  in  progressive 
muscular  atrophy  Is  secondary  to  the  involvement  of  the 
nerves,  whereas,  in  the  dystrophies  the  disturbance  lies 
primarily  in  the  muscles.  No  electrical  reactions  appear  In 
the  notes  of  this  case.     It  may,  however,  be  said   that  in 


84  CASE    HISTORIES    IN    NEUROLOGY. 

progressi\'e  muscular  atrophy  electrical  alterations  are  much 
more  conspicuous  than  in  the  dystrophic  conditions. 

Prognosis.  The  disease  often  occurs  in  several  members 
of  a  family,  as  appears  to  have  been  the  case  here.  Recovery 
does  not  take  place.  The  progress  of  the  disease  is,  however, 
exceedingly  slow. 

Treatment.  Treatment  of  this  condition  is  unavailing. 
Care  should  be  taken  not  to  over-exercise  the  already  weak- 
ened muscles.  The  lifting  which  this  girl  was  obliged  to  do 
should  not  be  permitted.  Massage  in  skilful  hands  may  be 
useful,  but  here  again  extreme  care  must  be  taken  not  to  tire 
the  muscles. 


SPINAL    CORD.  85 

Case  32.  O.,  when  first  seen  in  January,  1905,  was 
thirty-nine  years  old.  Five  years  before,  he  had  had  a  some- 
what serious  fall  from  a  bicycle,  but  had  recovered,  although 
he  was  inclined,  no  doubt  erroneously,  to  attach  importance 
to  this  fall  in  connection  with  his  later  developing  disease. 
Two  to  three  years  ago  he  had  noticed  gradually  increasing 
weakness  in  the  right  arm,  without  pain.  The  right  leg  had 
troubled  him  in  a  similar  way  so  that  he  had  had  difBculty 
in  going  up  and  down  stairs.  There  was  no  venereal  history, 
no  headache  or  disturbance  of  the  cranial  nerve  innervation. 
There  had  been  some  pain  across  the  shoulders  and  through 
the  spine,  but  of  indefinite  character. 

Physical  examination  showed  normal  pupillary  reactions. 
The  right  arm  was  evidently  weak  and  carried  close  to  the 
side.  The  right  shoulder  was  carried  somewhat  higher  and 
further  forward  than  the  left.  The  right  trapezius  was 
weak;  there  was  no  power  in  the  deltoid ;  the  biceps  was  very 
weak;  the  forearm  muscles  somewhat  stronger.  There  was 
atrophy  of  the  interossei,  difficulty  in  flexion  of  the  fin- 
gers and  considerable  general  weakness  of  the  hand  muscles. 
The  left  arm  also  was  weak  with  atrophy  of  muscles,  but  less 
marked  than  on  the  right.  Electrical  examination  showed 
that  most  of  the  muscles  were  still  responsive  to  faradism 
but  required  a  stronger  current  than  normal.  Reaction  of 
degeneration  was  obtained  in  the  right  biceps,  but  not  in  the 
small  hand  muscles.  In  the  left  arm  indirect  stimulation 
by  faradism  gave  good  reactions.  The  reflexes  of  the  arms 
were  not  exaggerated.  The  right  leg  was  much  smaller  than 
the  left,  the  measurements  being  i§  inches  less  about  the 
right  calf  than  about  the  left,  but  this  he  said  had  alw^ays 
been  so.  There  was  no  general  atrophy,  as  in  the  arms. 
The  knee  jerks  were  very  much  increased ;  there  was  double 
ankle  clonus;  the  Achilles  jerks  were  both  very  active;  there 
was  no  Babinski  sign  on  the  left  and  it  was  doubtfully  ob- 
tained on  the  right.  There  was  no  atrophy  of  the  small 
muscles  of  the  feet.  Sensation  and  sphincter  control  were 
unaffected.  The  heart  was  normal.  There  were  fibrillary 
movements,  especially  over  the  back  muscles.  The  urine 
showed  no  abnormality.     During  the  succeeding  six  years 


86 


CASE    HISTORIES    IX    NEUROLOGY 


the  condition  grew  very  gradually  worse,  but  with  its  essential 
features  unchanged.  The  disability  had  greatly  increased 
through  the  atrophy  of  muscles  and  consequent  contractures, 
and  the  spasticity  had  reached  such  a  point  that  walking 
was  almost  impossible,  especially  if  it  demanded  going  up 
or  down  stairs.  No  involvement  of  the  cranial  ner\^es  had 
developed  and  his  general  health  is  wholly  unimpaired. 

Diagnosis.  The  combination  in  this  case  of  atrophy, 
particularly  of  the  upper  extremities,  with  spasticity,  particu- 
larly of  the  lower  extremities,  without  sensory  or  sphincteric 
disturbance,  progressive  in  course  and  without  pain  over  the 
ner\'e  trunks,  permits  of  no  other  diagnosis  than  Amyo- 
trophic Lateral  Sclerosis  (progressive  muscular  atrophy  of  the 
spastic   type  [see  Fig.  5]).     Death   in   this    condition,   as  in 

spinal  progressive 
<!!^ ^.y^"^     I      />-\    cOf^  muscular    atrophy, 

usually  results 
through  ultimate 
extension  of  the 
process  to  the  ob- 
longata. 

Prognosis.  The 
progress  of  the  affec- 
tion especially  illus- 
trated by  this  case 
is  extremely  slow. 
Changes  from 
month  to  month  are  imperceptible;  from  year  to  year  the 
increasing  incapacity  may  be  noticed.  A  complication,  as  in 
all  highly  spastic  conditions,  is  the  development  of  contrac- 
tures with  the  consequent  increased  difficulty  of  locomotion 
or  of  the  proper  use  of  the  hands  and  arms.  In  this  patient 
a  contracture  of  the  pectoral  muscles  of  one  side  was  so 
great  and  the  resulting  disability  therefrom  so  incapacitat- 
ing that  a  muscle  cutting  vv-as  done  with  relief.  It  is  now 
almost  impossible  for  the  patient  to  get  about  or  to  attend 
to  his  personal  needs. 

Treatment.  IMechanical  treatment  vigorously  applied 
from  time  to  time  has  been  of  great  assistance  in  overcoming 


From  a  case  of  Amyotrophic  Lateral  Sclerosis ;  cervical  region, 
showing  coincident  involvement  of  ventral  horns  and  lateral 
(pyramidal)  tracts. 


SPINAL    CORD.  87 

the  tendency  to  contracture  and  in  relieving  the  spasticity. 
Massage  and  particularly  exercises  by  means  of  Zander 
apparatus  have  been  particularly  efficacious.  Hydrothera- 
peutic  measures  have  also  given  relief.  Drugs  have  been 
unavailing.  Surgical  intervention,  as  stated  above,  has 
accomplished  something  through  mechanically  improving 
the  posture. 


88  CASE    HISTORIES    IN    NEUROLOGY. 

Case  33.  G.,  forty-five  years  old,  had  been  married  six 
years  and  dated  the  beginning  of  his  symptoms  to  a  period 
slightly  before  that.  His  chief  complaint  was  pain  in  various 
parts  of  his  body,  feet,  legs  and  arms.  He  had  also  had  a 
girdling  sensation  with  practically  constant  pain  about  the 
body,  which  ran  up  the  back  and  into  his  head.  He  had  lost 
in  w^eight  and  generally  was  in  somewhat  poor  physical 
condition,  to  such  an  extent  that  he  had  not  worked  for  a 
year.  He  had  had  no  trouble  with  his  eyesight;  his  appetite 
in  general  was  good,  and  difficulty  in  walking  had  not  been 
a  conspicuous  annoyance.  The  pain,  which  he  described  as 
"  just  like  putting  a  knife  right  into  you,"  had  been  per- 
sistent and  distressing.  His  legs,  at  times,  had  felt  numb, 
his  arms  less  so.  He  had  had  no  difficulty  in  stomach  diges- 
tion, the  bowels  had  been  regular,  micturition  somewhat 
frequent,  possibly  associated  with  slight  incontinence.  He 
admitted  gonorrhea,  but  thought  he  had  not  had  syphilis. 
There  was  a  history  of  much  sexual  excess,  and  later  lack  of 
desire. 

Examination  showed  slightly  irregular  pupils  with  ex- 
tremely slight  light  reaction  and  excellent  accommodation. 
The  cranial  nerves  were  otherwise  normal.  The  arms  were 
very  slightly  ataxic,  but  otherwise  showed  no  abnormality 
in  sensation,  strength  or  reflexes.  The  knee  jerk  was  active 
on  the  right  but  obtained  with  great  difficulty  on  the  left, 
unless  reinforcement  were  used.  There  was  no  Achilles 
response,  no  Babinski,  no  clonus.  There  was  slight  ob- 
jective disorder  of  sensation  on  the  left  foot,  but  the  joint 
sensibility  was,  in  general,  adequate.  There  was  very  slight 
Romberg.  A  later  examination  showed  less  difference  in  the 
knee  jerk  of  the  two  sides. 

Diagnosis.  This  is  evidently  a  typical  case  of  Tabes  in  a 
somewhat  early  stage.  The  characteristic  pain  would  be 
sufficient  to  make  a  highly  probable  diagnosis  even  in  the 
absence  of  the  pupillary  changes  and  the  altered  reflexes. 
Lancinating  pain  is  an  early,  almost  constant  and  exceed- 
ingly important  symptom  of  tabes.  The  pain  is  characterized 
by  shifting  locality,  frequency  in  muscular  regions,  sudden 
onset   and   disappearance,    sharp   quality   well   described   as 


SPINAL    CORD.  89 

lancinating.  It  is  often  popularly  mistaken  for  rheuma- 
tism. 

Prognosis.  Tabes  is  not  in  itself  a  fatal  disease.  Death 
occurs  from  complications  usually  on  the  part  of  the  kidneys 
and  bladder  rather  than  from  the  invasion  of  vital  areas  by 
the  progressive  nerve  degeneration.  In  this  case  the  outlook 
for  a  long  period  of  relative  usefulness  is  good,  provided  the 
patient  adheres  to  a  strict  manner  of  life  and  avoids  excesses 
of  all  sorts. 

Treatment.  The  important  elements  in  the  treatment 
are,  relief  of  immediate  symptoms,  training  in  coordination 
and  care  of  the  bladder.  The  lancinating  pains  are  difficult 
to  combat.  Aspirin  is  useful  to  palliate  the  pain,  but  is 
wholly  inefficient  to  control  a  severe  paroxysm.  Morphine 
is  often  a  necessary  resort  and  codeine  by  mouth  is  frequently 
useful  although  both  It  and  morphine  should  be  used  as 
sparingly  as  possible.  The  gastric  crises  are  self-limited 
and  must  be  treated  on  the  general  principles  applying  to 
extreme  pain.  Coordinative  exercises  following  the  direc- 
tions given  by  Fraenkel  were  employed  in  this  case  with 
excellent  results.  This  form  of  treatment  should  be  urged 
upon  patients  before  the  ataxia  has  become  so  extreme  as 
to  render  it  relatively  inefficacious.  The  urine  should  be 
examined  repeatedly,  and  urotropin  should  be  given  to  ward 
off  cystitis.  If  there  is  residual  urine,  bladder  washings  should 
be  systematically  carried  out.  By  scrupulous  care  in  these 
regards,  there  is  no  doubt  that  life  may  be  materially  pro- 
longed. Regularity  in  the  passage  of  urine  does  much  to 
overcome  retention  and  Incontinence.  The  administration  of 
salvarsan  (Ehrlich's  "  606")  is  still  in  its  experimental  stage. 
Favorable  reports  are  at  hand,  but  the  procedure  should 
not  be  made  a  general  one  until  a  much  wider  experience  of 
Its  action  accumulates  in  the  treatment  of  other  than  the 
metasyphilitic  affections. 


90  CASE    HISTORIES    IN    NEUROLOGY. 

Case  34.  I.,  married,  fifty-one  years  old,  had  been  exposed 
to  venereal  infection  fifteen  years  ago;  immediately,  there- 
after, he  had  had  persistent  sore  throat,  but  no  other  signs 
of  syphilis,  and  no  known  local  sore.  He  was  well  until  about 
four  years  ago,  when  he  began  to  have  sharp  pain  in  the 
axillae  and  legs,  which  continued  to  the  time  of  examination 
in  May,  1910.  The  pain  was  at  times  so  severe  as  to  demand 
morphine.  Three  or  four  years  before  he  had  a  paralysis 
of  the  right  lid,  which  had  never  wholly  recovered.  Be- 
ginning in  1909  he  had  gradually  lost  the  sight  of  that  eye; 
he  had  had  no  trouble  with  the  left  eye,  and  there  was  no 
history  of  diplopia.  Very  slight  difhculty  in  walking  had 
developed;  it  had  become  difficult  to  pass  urine  freely,  but 
there  had  been  no  incontinence;  sexual  desire  had  diminished. 
There  had  been  no  girdling  pains,  no  vomiting  or  stomach 
difficulty.  He  had  not  observed  any  unusual  numbness  of 
arms  or  legs,  and  he  was  able  to  write  well.  In  spite  of  the 
pains  which  were  of  daily  occurrence  he  had  continued  at 
his  work  in  a  factory.     The  bowels  had  been  costive. 

Examination  showed  unequal  pupils,  the  right  slightly 
larger  than  the  left;  no  light  reaction  in  the  right;  consid- 
erable in  the  left  with  good  accommodation  in  both.  The 
right  optic  nerve  was  atrophied.  Except  for  slight  per- 
sistent ptosis  of  the  right  lid,  the  cranial  nerves  showed  no 
further  involvement.  There  was  slight  ataxia  of  the  arms, 
with  unimpaired  strength,  and  normal  objective  sensibility. 
Knee  jerks  and  Achilles  reflexes  were  not  obtained;  there 
was  no  ankle  clonus,  and  the  plantar  response  was  difficult 
to  determine  on  account  of  extreme  ticklishness  of  the  soles. 
The  Romberg  sign  was  slightly  present.  The  heart,  pulse 
and  blood  pressure  were  normal. 

Diagnosis.  The  presence  of  an  Argyll-Robertson  pupil, 
lancinating  pains,  sphincteric  disorder,  with  absence  of 
knee  jerks,  makes  this  an  unmistakable  case  of  Tabes.  In 
the  early  stages,  marked  objective  disorders  of  sensation  are 
often  conspicuously  absent,  which  accounts  for  the  slight 
development  of  the  Romberg  sign.  Syphilis  is  presumably 
a  constant  etiological  factor  in  tabes,  and  may  frequently 
be  demonstrated  in  those  cases  where  the  original  infection 


SPINAL    CORD.  91 

passed  unnoticed,  by  the  recently  perfected  Wassermann 
serum  test.  Certain  types  of  neuritis  (see  Case  2)  may 
closely  simulate  tabes,  but  in  the  former  motor  weakness 
and  pain  on  pressure  over  nerve  trunks,  in  the  absence  of 
Argyll-Robertson  pupils  and  sphincteric  disorder,  should 
usually  determine  the  diagnosis.  Sharp  pains  may  occur  in 
both  conditions,  but  they  are  much  less  characteristic  in 
neuritis,  and  do  not,  as  in  tabes,  extend  over  many  years  — 
often  ten  or  more. 

Prognosis.  With  care,  this  patient  should  live  for  many 
years  with  gradually  decreasing  usefulness.  The  fact  that 
he  has  lost  the  sight  of  one  eye  through  optic  atrophy  renders 
it  probable  that  the  other  eye  will  ultimately  undergo  the 
same  degeneration. 

Treatment.  The  treatment  in  this  case  was  relief  of  the 
pain,  together  with  general  directions  as  to  living  and 
exercises,  as  indicated  under  Case  33. 


92  CASE    HISTORIES    IN    NEUROLOGY. 

Case  35.  C,  a  woman  fifty  years  old,  three  years  before 
being  seen  had  had  pain  in  one  heel.  Thereafter  she  stated 
that  she  was  paralyzed  from  her  waist  down,  both  as  regards 
sensation  and  motion.  She  was  in  bed  for  three  months 
and  gradually  recovered  from  the  paralytic  condition.  The 
pain  extended  into  the  knees  and  there  was  considerable 
numbness  in  the  legs  with  a  staggering  gait  which  had  per- 
sisted up  to  the  time  of  the  examination.  There  had  been  no 
trouble  with  the  sphincters. 

Examination  showed  irregular  pupils,  the  right  responding 
to  light  much  better  than  the  left,  which,  however,  retained 
some  slight  light  reaction.  The  accommodation  was  normal, 
the  fields  normal,  and  the  cranial  nerves  otherwise  unin- 
volved.  There  was  slight  ataxia  of  the  arms  without  demon- 
strable sensory  disorder.  The  strength  of  the  legs  was  unim- 
paired; there  was  no  knee  jerk,  no  Achilles  reflex  and  no 
plantar.  There  was  blunting  of  sensation  with  disordered 
sense  of  position  in  the  feet,  associated  with  an  extreme  degree 
of  swaying  with  the  eyes  closed  (Romberg  sign).  There  was 
some  rigidity  of  the  radial  arteries  and  a  systolic  murmur 
at  the  heart  base.  The  pulse  was  regular  and  of  normal 
rapidity. 

Diagnosis.  This  patient  undoubtedly  was  suffering  from 
Tabes.  The  pupillary  condition,  sensory  disorders  of  the  legs 
and  absent  deep  reflexes,  with  retained  motor  power,  are 
sufficient  to  confirm  the  diagnosis.  The  original  attack,  three 
years  before,  with  an  asserted  paralysis  of  the  legs,  is  not 
possible  to  interpret  on  the  basis  of  tabes.  It  is  probable 
the  observ-ation  of  the  patient  was  incorrect,  and  that  either 
the  paralysis  was  not  so  complete  as  she  supposed  or  that  the 
sensory  and  motor  disturbance  extended  beyond  the  legs 
to  other  parts  of  the  body.  In  that  case,  a  peripheral  neuritis 
would  be  explanatory.  A  myelitis  would  not  have  shown  so 
complete  a  recovery.  In  any  case,  the  symptoms  as  observed 
three  years  later  were  typically  those  of  tabes. 

Prognosis  and  Treatment  in  this  case  are  not  different  from 
that  already  outlined. 


SPINAL    CORD.  93 

Case  36.  A.,  thirty-nine,  married,  one  child  fifteen  years 
old,  had  suffered  for  ten  years  with  pain  in  her  back,  shoulder 
blades  and  also  lower  down.  She  had  been  distended  with 
gas,  constipated  and  at  times  slightly  jaundiced.  She  had 
had  difficulty  with  her  stomach  for  which  she  had  been  treated 
since  the  age  of  twenty.  At  nineteen  she  had  had  pain  in  the 
neighborhood  of  the  left  breast  with  general  weakness.  At 
the  time  of  examination  she  had  many  complaints  of  sensa- 
tions of  heaviness,  weakness,  shortness  of  breath,  vertigo, 
occipital  pain  and  pains  in  the  limbs.  She  maintained,  how- 
ever, that  she  has  not  worried  about  these  disorders. 

Examination  showed  the  right  pupil  much  smaller  than 
the  left,  with  no  light  reaction  whatever,  but  with  retained 
accommodation;  the  fundus  was  pale  on  both  sides;  the 
elbow  jerks  were  active;  the  knee  jerks  normal;  there  was 
slight  swaying  with  the  eyes  closed.  The  heart  showed  no 
abnormality;  pulse  96,  regular;  blood  pressure  about  130. 
On  further  questioning  it  appeared  that  for  some  years  she 
had  had  sharp  lancinating  pains  in  the  legs,  that  her  stomach 
disturbance  certainly  of  late  was  also  associated  with  pain 
and  came  rather  in  attacks  than  as  a  constant  disability. 
It  appeared  also  that  at  one  time  she  had  been  catheterized 
for  three  days.  The  feet  and  hands  were  usually  cold,  but 
there  were  no  other  subjective  disorders  of  sensibility. 

Diagnosis.  This  case  had  been  taken  for  one  of  psy- 
chasthenla  and  no  suspicion  of  organic  disease  had  been 
entertained.  The  combination,  however,  of  Argyll-Robertson 
pupil  with  very  typical  lancinating  pains,  together  with 
transient  disturbance  with  the  sphincters  and  presumable 
gastric  crises  renders  the  diagnosis  of  Tabes  practically  certain 
in  spite  of  the  persistence  of  the  deep  reflexes,  notably  of 
the  knee  jerks.  It  is,  however,  probable  that  in  this  case 
there  is  a  combination  of  psychasthenia  of  long  persistence 
with  tabes  of  more  recent  development.  The  interest  of  the 
case  from  a  diagnostic  standpoint  lies  in  this  fact.  It  would 
be  well  to  make  a  thorough  objective  sensory  examination 
and  to  determine  the  possibility  of  earlier  syphilitic  infection. 

Prognosis.  So  far  as  the  tabetic  process  is  concerned  this 
patient  should  do  well.     The  situation  is,  however,  compli- 


94  CASE   HISTORIES    IN    NEUROLOGY. 

cated  by  her  definite  psychasthenic  attitude,  which  pre- 
sumably will  not  tend  to  shorten  her  life  but  which  will 
undoubtedly  render  it  much  more  miserable  than  it  otherwise 
would  have  been  with  the  handicap  alone  of  tabes. 

Treatment.  The  tabes  should  be  treated  on  general  prin- 
ciples. The  psychasthenic  state  demands  careful  investigation 
to  the  end  that  its  causes  may  be  discovered  and  mental 
means  provided  to  meet  the  situation.  The  patient  has  passed 
from  observation. 


SPINAL    CORD.  95 

Case  37.  L.,  thirty-nine  years  old,  stated  that,  six  months 
before,  he  had  noticed  dimness  of  vision,  which  had  increased. 
There  was  special  difhculty  in  differentiating  colors,  so  that 
his  capacity  for  work,  that  of  a  salesman,  was  seriously 
affected.  Fourteen  years  before  he  had  had  "  rheumatism  " 
with  sharp  pain  in  his  right  leg,  which  came  and  went  quickly. 
He  had  had  some  "  twinges  "  since  in  that  leg  but  only  after 
exercising.  These  pains  were  also  sharp,  quickly  over  and 
not  severe.  Gonorrhea  was  acknowledged,  syphilis  denied. 
He  had  formerly  been  a  heavy  drinker,  but  when  seen  and 
for  some  years  previously  had  neither  smoked  nor  taken 
alcohol.  In  general,  except  for  the  condition  of  his  eyes, 
he  considered  himself  well.  Questioning  showed  that  he  had 
at  no  time  had  difficulty  in  micturition,  uncertainty  of  gait, 
girdling  sensation  or  other  disorder  of  sensibility. 

Physical  examination  revealed  slightly  unequal  pupils; 
no  light  response  with  retained  accommodation  (Argyll- 
Robertson  pupil)  and  pronounced  optic  nerve  atrophy. 
There  was  no  ataxia  of  the  arms;  the  knee  jerks  were  active; 
there  were  no  objective  sensory  disorders  and  no  swaying 
with  the  eyes  closed  (Romberg  sign).  The  heart  was  normal, 
pulse  80  and  blood  pressure  140. 

Diagnosis.  The  combination  of  lancinating  pains,  Argyll- 
Robertson  pupil,  with  optic  atrophy,  makes  the  diagnosis 
of  Tabes  certain  in  this  case,  in  spite  of  active  knee  jerks 
and  the  failure  of  other  signs.  The  superior  type  of  tabes, 
characterized  by  early  optic  atrophy,  is  usually  for  a  long 
period  unassociated  with  other  signs,  justifying  in  part, 
or  at  least  explaining,  the  statement  that  the  usual  tabetic 
symptoms  are  checked  by  optic  nerve  atrophy.  The  con- 
fusion of  lancinating  pains  with  "  rheumatism  "  in  the  mind 
of  the  patient  should  always  be  borne  In  mind.  It  should 
also  be  remembered  that  tabes  is  one  of  the  few  conditions 
in  which  primary  atrophy  of  the  optic  nerve  occurs. 


96  CASE   HISTORIES    IN    NEUROLOGY. 

Case  38.  C,  thirty-four  years  old,  was  admitted  to  a 
hospital  March  i,  1898.  Her  occupation  had  been  circus 
riding.  In  her  family  history  the  only  points  of  Importance 
were,  that  her  mother  had  died  of  tuberculosis  and  that  of 
seven  brothers  and  sisters  but  one  Is  now  living,  one  of  the 
others  having  died  of  tuberculosis  and  one  of  meningitis. 

The  history  given  was  that  in  1889  she  was  thrown  from 
a  horse  but  not  seriously  hurt.  She  was  able  to  go  on  with 
her  work  and  noticed  no  other  symptoms  than  sharp  pains. 
During  the  years  1890  and  1891  she  noticed  occasional  dis- 
turbances of  sensation  In  the  sole  of  the  left  foot  and  In  the 
right  knee.  She  discontinued  her  work  as  circus  rider  for 
two  years.  In  1894  she  began  work  again,  riding  as  before, 
but  not  so  well.  There  appears  to  have  been  at  this  time  some 
disturbance  of  sensation  and  some  ataxia,  especially  after 
excessive  exercise.  She  worked,  however,  for  two  years, 
until  1896,  but  discontinued  riding.  She  still  had  pains.  In 
1897  she  fell  a  distance  of  four  steps,  striking  on  the  lower 
part  of  her  spine,  but  continued  to  work  for  three  weeks  with 
a  gradual  feeling  of  unsteadiness  while  on  her  feet.  At  the 
end  of  these  three  weeks  she  had  a  sudden  feeling  of  faintness 
and  quickly  and  completely  lost  control  of  her  legs.  They 
felt  "  dead."  She  was  unable  to  go  upstairs,  and  urinary 
disorders  set  In.  She  suffered  Intensely  from  stomach  pain 
associated  with  vomiting,  —  typical  gastric  crises,  girdle 
pains,  excessive  constipation  and  occasional  definite  delirium. 
She  had  undoubtedly  contracted  syphilis  from  her  first 
husband,  and  had  been  to  a  certain  extent  addicted  to  alco- 
holic liquors.  She  had  suffered  from  dysmenorrhea  and 
irregular  menstruation  as  long  as  she  could  remember,  and 
also  stated  that  she  had  had  Incontinence  of  urine  until 
her  twelfth  year.  She  had  had  two  living  children,  both  of 
whom  died  In  Infancy,  and  four  miscarriages;  two  children 
had  been  born  prematurely  and  two  were  stillborn.  The 
patient  was  also  possessor  of  a  so-called  elastic  skin. 

Ph^^slcal  examination  In  the  hospital  showed  a  somewhat 
emaciated  woman,  wholly  incapable  of  standing,  even  with 
considerable  assistance.  The  knee  jerks  were  absent.  The 
pupils  failed  to  respond  to  light  but  continued  to  respond  on 


SPINAL    CORD. 


97 


accommodation.  The  condition  of  the  legs  showed  no  muscular 
atrophy,  but  a  very  marked  flaccidity  at  the  joints.  Gross 
strength  was  not  impaired  but  incoordination  was  absolute. 
Examination  of  sensation  showed  a  complete  absence  of  all 
forms  in  the  legs  extending  up  to  the  abdomen. 

While  in  the  hospital  she  had  various  attacks,  differing 
in  character,  of  mental  disturbance.  At  one  period  she  showed 
considerable  evidence  of  mental  excitement,  threatening 
suicide  and  manifesting  various  unsystematized  delusions. 
Later,  for  a  period  of  about  two  months  or  more,  she  was 
apparently  in  a  deeply  depressed  condition,  refusing  ab- 
solutely to  talk  and  manifesting  no  Interest  whatever  in  her 
surroundings.  During  this  period  she  at  times  refused  to 
take  food,  was  stuporous,  lay  with  eyes  half  closed,  moved 
but  little  and  required  artificial  feeding.  She  answered  no 
questions  and  appeared  not  to  understand  the  significance 
of  the  bedpan.  She  made  no  complaints  at  this  time  of 
physical  pain,  and  at  times  Indicated  by  a  nod  that  she  felt 
better.  Following  this  there  was  a  period  of  cheerfulness 
associated  with  more  or  less  incoherent 
talk.  This  also  passed  and  she  finally 
apparently  became  entirely  rational  and 
capable  of  Interesting  herself  to  a  certain 
extent  In  affairs  about  her.  She  also  suf- 
fered Intensely  at  times  from  gastric  crises. 
Examination  of  the  Internal  organs  at  no 
time  until  toward  the  end  of  her  life  showed 
any  abnormality.  Under  these  conditions 
she  gradually  failed,  and  death  finally  re- 
sulted, January  27,  1901,  with  development 
of  ulcers  and  bedsores,  facial  erysipelas 
and  a  terminal  pneumonia. 

Autopsy.  Autopsy  very  shortly  after 
death  showed  a  certain  amount  of  pleuri- 
tis;  edema  of  the  lungs,  with  areas  of  tuber- 
culosis; degeneration  of  the  dorsal  col- 
umns of  the  cord  and  an  apparent  atrophy 

r  •  .  f        1  ,  .  rr^i  F'°-  '+•     Cask  3S. 

of  certam  portions  of  the  bram.  There  s,,tions  through  cervkai. 
was  also  cloudy  swelling  of  the  liver  and  ^s^owi^^g  ^SfsarS'eVeSn: 


98  CASE    HISTORIES    IX    NEUROLOGY. 

kidneys,  r^licroscopic  examination  showed  an  extensive  and 
typical  tabetic  degeneration  throughout  the  cord,  evidently 
of  long  standing. 

Diagnosis.  There  was  at  no  time  difficulty  in  the  diagnosis 
of  this  case.  The  altogether  probable  venereal  history^  to- 
gether with  early  sharp  pain,  sensory  disorder,  ataxia  and 
later  lost  reflexes  and  characteristic  pupillary  changes  render 
certain  the  diagnosis  of  Tabes.  The  case  is  of  interest,  es- 
pecially from  the  associated  disturbed  mental  state  which 
justified  the  diagnosis  borne  out  by  the  autopsy,  that  the 
tabes  was  associated  with  cortical  degeneration  of  the  nature 
of  dementia  paralytica.  The  diagnosis  may,  therefore, 
properly  be  made  of  so-called  Tabo-paralysis.  This  is  a 
not  infrequent  combination  and  justifies  the  assumption  of 
a  common  etiology  of  the  two  affections  and  their  general 
similarity  except  in  relation  to  the  portion  of  the  nervous 
system  mainly  affected. 

Prognosis.  The  patient  was  carefully  nursed  at  the  hos- 
pital, but  died  finally  of  ulcers  and  bedsores  with  an  ulti- 
mate facial  er>^sipelas  and  terminal  pneumonia.  She  had 
lived  about  twelve  years  from  the  onset  of  the  first  symptoms. 

Treatment.  When  this  patient  came  under  observation 
her  disease  was  far  ad\-anced.  Treatment,  therefore,  con- 
sisted merely  in  rendering  her  as  comfortable  as  her  dis- 
tressing condition  allowed.  Her  various  symptoms,  gastric 
crises,  lancinating  pain  and  discomforts  both  mental  and 
physical  were  treated  as  they  arose.  (See  previous  cases  of 
tabes.) 


SPINAL   CORD.  99 

Case  39.  A.,  a  man  of  forty-nine,  unmarried,  was  admitted 
to  a  hospital,  June  8,  1901.  Nothing  of  his  family  history 
bearing  on  the  present  condition  was  obtained.  He  had 
had  typhoid  fever  when  a  young  man  and  in  1882  syphilis, 
for  which  he  was  treated  with  apparent  success.  Since  1888 
he  had  taken  alcohol  in  excess. 

About  three  years  before  entrance  to  the  hospital  he  noticed 
a  dull,  constant  pain  which  occupied  small  areas  at  the  front 
of  the  abdomen  at  the  level  of  the  umbilicus.  He  did  not 
notice  any  pain  in  his  back.  He  had  no  nausea.  He  took 
medicine  which  seemed  to  improve  the  condition  but  led  to 
a  facial  eruption.  At  the  end  of  a  year  he  was  relieved  of  this 
pain,  but  in  the  summer  of  1898  he  noticed  a  cold  area  about 
the  size  of  a  hand  just  below  both  knees.  This  gradually 
enlarged  and  a  feeling  of  numbness  supervened  in  the  cold 
areas.  His  feet  became  involved  in  the  sensory  disorder  and 
he  felt  as  though  "  walking  on  a  thick  carpet."  In  the  winter 
of  1899  paresthesia  of  the  legs  developed,  and  his  knees  felt 
as  though  "  in  a  vise."  These  disorders  of  sensation  involved 
the  legs  from  below  upwards.  During  this  period  and  up  to 
April,  1900,  he  was  able  to  walk  steadily,  whether  in  light  or 
dark,  and  had  no  disorder  either  with  his  sight  or  hand- 
writing. Since  that  time,  however,  his  eyesight  had  gradually 
failed,  so  that  at  the  tim_e  of  entrance  to  the  hospital  he  was 
wholly  unable  to  read.  His  fingers  had  also  begun  to  feel 
clumsy  and  cold,  but  there  was  no  paresthesia  or  numbness 
of  the  arms.  His  handwriting  became  much  impaired. 
In  February,  1901,  he  noticed  a  feeling  of  cold  which  gradually 
extended  from  the  legs  up  to  the  level  of  the  nipple.  Up  to 
six  months  before  entrance  he  was  able  to  walk,  then  gradually 
lost  power  in  his  legs  until  they  were  practically  totally 
helpless.    He  had  no  disturbance  of  deglutition  or  articulation. 

Physical  examination  showed  a  poor  reaction  on  the  part 
of  the  pupils  both  to  light  and  with  accommodation.  His 
vision  was  poor.  He  could  not  count  fingers  at  a  distance  of 
ten  feet,  nor  could  he  read  ordinary  type.  Lungs  and  heart 
were  normal.  A  slight  fibrillary  twitching  was  noted  over  the 
pectoral  region  and  in  the  muscles  of  the  upper  arm.  His 
hand   grasp   was   good,   but   there   was   general   disturbance 


100 


CASE   HISTORIES    IN    NEUROLOGY. 


ooo, 


of  temperature  sense  over  the  body  and  arms.  His  legs 
and  toes  could  be  moved  very  slightly.  His  legs  assumed 
a  semi-flexed  position.  The  knee  jerks  were  very  much  in- 
creased; ankle  clonus  and  Babinski  reaction  were  present. 
The  tactile  sense  also  showed  some  impairment.  Later  a 
marked  disturbance  in  control  of  the  sphincters  came  on  and 
a  certain  mental  failure  became  apparent.  The  hemoglobin 
was  60%;  whites,  12,800;  reds,  5,284,000. 

On  June  28,  1901,  it  was  noted  that  the  patient  was  pro- 
gressively failing,  both  physically  and  mentally.  He  had  be- 
come emaciated,  was  dirty  in  his  habits  and  practically 
helpless.    He  died  July  8,  1901. 

Autopsy.     The  post-mortem  examination  showed  a  high 
degree  of  arteriosclerosis  of  the  vertebral  arteries  and  of  the 
A  circle  of  Willis,  together  with  an 

appearance  of  atrophy  of  certain 
portions  of  the  brain  surface. 
Frontal  sections  of  the  brain 
showed  cystic  formation  in  the 
region  of  the  internal  capsule. 
The  spinal  cord  showed  a  definite 
diffuse  combined  generation 
localized  predominantly  in  the 
dorsal  and  lateral  tracts.  The 
microscopic  appearances  were 
neuroglia  sclerosis  combined 
with  vacuole  formation  and  fat 
granule  cells  in  the  degenerating 
area  with  accompanying  degen- 
eration of  myelin.  The  degen- 
eration was  most  pronounced  in 
the  thoracic  and  cendcal  regions. 
The  oblongata  was  entirely 
spared. 

Diagnosis.  The  etiology  in 
this  case  was  obscure  beyond  the 
fact  of  a  general  arteriosclerosis. 
The  clinical  diagnosis  substan- 
tiated  by  autopsy  was   Diffuse 


Fig.  15.    Case  39. 
A,  cervical  ;  B,  thoracic;  C,  lumbar,  showing 
diffuse  lesions  in  a  case  without  anemia.     Accu- 
rate tracings,  Edinger  drawing  apparatus. 


SPINAL   CORD.  lOI 

Combined  Degeneration  of  the  spinal  cord,  giving  rise  to  the 
symptom  complex  of  Ataxic  Paraplegia.  This  condition  is  to 
be  distinguished  from  a  transverse  myelitis  by  the  fact  that 
various  regions  of  the  cord  are  invaded  and  that  the  onset  is 
insidious.  When  the  disease  is  well  established,  confusion  may 
arise  between  these  two  conditions.  It  is  to  be  sharply  distin- 
guished from  tabes  by  the  general  exaggeration  of  the  re- 
flexes and  the  absence  of  Argyll-Robertson  pupil  and  lancinat- 
ing pains.  The  conspicuous  sensory  disorders  are  sufificient 
to  separate  it  from  amyotrophic  lateral  sclerosis.  Pain  and 
localizing  signs  should  usually  prevent  confusion  with  a  spinal 
tumor  (in  this  connection  see  Case  56). 

Prognosis.  The  prognosis  is  ultimately  bad,  but  the  course 
of  the  disease  is  extremely  variable  and  impossible  to  pre- 
dict with  any  degree  of  certainty.  It  not  infrequently  runs 
its  course  in  from  one  to  two  years  from  the  appearance  of 
the  first  symptoms,  or  again  it  may  extend  with  varying 
intensity  over  a  period  of  many  years.  Our  present  knowledge 
does  not  permit  us  sharply  to  subdivide  the  different  varieties 
of  the  general  lesion. 

Treatment.  Treatment  should  be  directed  toward  the 
general  condition  rather  than  toward  the  definite  lesions  of 
the  cord.  Occurring  as  the  disease  often  does  in  cachectic  indi- 
viduals, a  general  supportive  and  tonic  treatment  is  desirable. 
Regulation  of  the  diet,  exercise  and  general  hygiene  are  far 
more  important  than  drugs.  Strychnia  may  be  used  with 
discrimination,  and  massage  and  electricity  fill  a  certain 
place.  The  Fraenkel  coordinative  exercises  are  far  less  useful 
in  this  condition  than  in  the  uncomplicated  ataxia  of  tabes. 


102  CASE   HISTORIES    IN    NEUROLOGY. 

Case  40.  S.,  a  woman  sixty  years  old,  unmarried,  a  seam- 
stress, was  well  up  to  the  spring  of  1900  except  for  occasional 
attacks  of  rheumatism.  She  then  began  to  have  sensations 
of  numbness  in  the  fingers,  but  not  affecting  the  body  or  the 
arms.  In  spite  of  the  fact  that  her  fingers  felt  as  if  "  asleep," 
she  was  able  to  sew  and  make  highly  coordinated  movements. 
In  July  she  began  to  have  similar  sensations  in  her  toes, 
which  gradually  spread  until  in  October  both  legs  were  en- 
tirely involved.  Excepting  for  the  numbness  she  considered 
herself  perfectly  w^ell.  There  was  no  disturbance  in  walking. 
Her  appetite  was  good  and  her  bowels  regular;  nothing  of 
importance  was  learned  regarding  her  family  history.  Seen 
October  8,  1900,  she  had  an  anemic  appearance  and  her  gait 
was  slightly  ataxic.  Heart  and  pupils  showed  no  abnormality. 
The  knee  jerks  were  slight. 

A  blood  examination,  November  20,  gave  the  following 
results:  Hemoglobin,  25%;  red  cells,  1,850,000.  Differen- 
tial count  of  500  white  cells;  polymorphonuclear  neutrophiles, 
71.8%;  basophiles,  small,  25.2%;  basophiles,  large,  1.6%; 
eosinophiles,  1.4%.  In  the  white  count  two  megaloblasts 
and  four  normoblasts  were  seen.  There  was  considerable 
poikilocytosis;  many  oval  forms;  excess  of  macrocytes; 
some    microcytes. 

On  December  5  a  note  was  made  that  the  legs  were  very 
rapidly  becoming  weak  and  ataxic  so  that  the  patient  was 
able  to  walk  but  a  few  steps  at  a  time  and  very  unsteadily. 
December  18  she  entered  a  hospital,  remaining  until  April  29. 
During  that  period,  under  general  tonic  and  hygienic  treat- 
ment, she  irpiproved  considerably.  A  second  blood  examina- 
tion showed  a  still  further  reduction  in  the  red  cells  with 
poikilocytosis,  hemoglobin  45%  and  14,000  white  cells. 

After  leaving  the  hospital  she  began  again  to  fail,  although 
her  appetite  remained  good.  She  became  more  ataxic  and 
by  the  middle  of  July  could  not  move  her  legs  while  in  bed, 
and  very  imperfectly  while  sitting  in  a  chair.  She  could  not 
stand  alone.  Her  bowels  were  very  constipated,  with  about 
one  movement  a  week,  in  spite  of  attempts  at  catharsis. 
August  15,  without  warning,  she  fell,  was  taken  up  uncon- 
scious and  remained  so  for  several  hours.    She  was  then  de- 


SPINAL    CORD. 


103 


lirious  and  helpless,  vomited  once  or  twice  and  had  excessive 
diarrhea  for  several  days.  She  failed  rapidly  and  died,  August 
30,  without  recovering  complete  consciousness. 

Autopsy.  Examination  of  the  cord  macroscopically  showed 
small  evidence  of  the  lesion.  On  microscopic  examination 
degenerations  in  the  white  matter, 
sharply  limited  to  the  dorsal  and 
lateral  tracts,  were  evident,  the 
type  of  degeneration  similar  to 
that  described  in  Case  39.  In  the 
thoracic  region  the  lesions  were 
distributed  as  in  the  cervical,  over 
the  dorsal  and  lateral  columns.  In 
the  lumbar  region,  on  the  other 
hand,  sclerosis  was  limited  to  the 
pyramidal  tracts.  Except  for  ex- 
treme pigmentation,  the  ventral 
horn  cells  were  normal. 

Diagnosis.  Cord  lesions  of  the 
type  of  combined  degenerations 
appearing  clinically  as  Ataxic  Para- 
plegia are  frequent  in  Anemia  of 
the  pernicious  type.  In  all  cases, 
therefore,  of  sensory  disorder  com- 
bined with  spasticity  the  blood 
should  be  examined,  and,  con- 
versely, in  anemias  the  nervous 
system  should  be  carefully  inves- 
tigated with  special  reference  to  the 
existence  of  this  lesion.  Sensation 
and  the  condition  of  the  reflexes  should  have  been  examined 
in  this  case.    For  differential  diagnosis,  see  Case  39. 

Prognosis.  The  outcome  of  cases  associated  with  perni- 
cious anemia  depends  rather  upon  the  blood  state  than  upon 
the  cord  lesion. 

Treatment.  Treatment  should  therefore  be  directed  toward 
improving  the  condition  of  the  blood  by  diet,  iron,  arsenic 
and  general  hygienic  measures. 


Fig.  16.     Case  40. 

A,  cervical  ;  B,  thoracic ;  C,  lumbar, 
showing  somewhat  circumscribed  lesions  in 
a  case  with  pernicious  anemia.  Accurate 
tracings,  Edinger  drawing  apparatus. 


104  CASE    HISTORIES    IN    NEUROLOGY. 

Case  41.  E.,  an  unmarried  woman  of  forty,  gave  the  follow- 
ing history.  She  had  been  well  up  to  nineteen,  then  when  at 
school  she  began  to  walk  with  difficulty,  so  that  in  a  short 
time  she  was  unable  to  get  about  unassisted.  Attempts 
at  treatment  did  not  result  in  improvement.  At  the  end  of 
six  months  she  was  wholly  unable  to  walk  and  felt  cold  and 
numb  to  her  waist  line.  After  this,  she  apparently  improved 
somewhat  but  soon  lost  what  she  had  gained,  so  that  for  the 
past  ten  years  she  had  been  totally  helpless  so  far  as  the  con- 
trol of  her  legs  was  concerned.  In  addition  to  the  motor 
disability,  she  had  had  much  sensory  disorder  in  the  legs  with 
partial  loss  of  sphincter  control,  marked  by  both  retention 
and  incontinence,  especially  when  lying  down.  Some  cystitis 
had  developed. 

On  examination  the  cranial  ner\^es  showed  no  involvement. 
The  pupils  were  normal  and  equal  and  reacted  properly  to 
light  and  on  accommodation;  the  visual  fields  were  normal. 
The  arms  were  not  paralyzed  and  gave  lively  normal  reflexes 
at  elbows  and  wTists,  with  unimpaired  sensation.  There 
were  no  abdominal  reflexes.  Below  a  line  three  to  four  inches 
above  the  umbilicus,  extending  around  the  body  at  that  level, 
there  was  absolutely  no  sensation  to  prick  or  contact. 
Muscular  sensibility  was  entirely  lacking.  At  and  below  the 
right  knee  there  were  scars,  apparently  the  result  of  burns. 
The  knee  jerks  were  greatly  increased;  there  was  no  ankle 
clonus,  presumably  on  account  of  contractures;  there  was 
double  Babinski  sign;  the  Achilles  jerks  were  not  obtained. 
The  back  showed  no  deformity.  There  was  an  escape  of  urine 
during  the  examination. 

Diagnosis.  The  etiology  in  this  case  is  obscure.  Tuber- 
culosis (Pott's  disease)  is  a  common  cause  of  transverse  lesion 
of  the  cord,  particularly  in  young  persons.  The  fact  that  no 
kyphos  had  developed  is  presumptive  evidence  that  this  was 
not  the  cause  in  this  instance.  There  was  no  history  of  an 
acute  infection,  the  process  w^as  somewhat  gradual  in  reach- 
ing its  height,  and  there  has  been  no  change  for  ten  years. 
Tumor  of  the  cord  may  be  excluded  because  of  the  lack  of 
pain  and  the  evident  stationary  character  of  the  process. 
The  exact  cause  of  the  lesion  must,  therefore,  be  left  undecided. 


SPINAL   CORD. 


105 


Its  results  are  evident,  namely,  a  practically  complete  trans- 
verse lesion  of  the  cord  in  the  lower  thoracic  region.  That  the 
lesion  was  not  completely  destructive  of  the  cord  is  shown 
by  the  fact  that  the  reflexes  were  retained  and  active  in  the 
legs.  (In  man,  experience  shows  that  a  complete  transection 
of  the  cord  permanently  destroys  the  deep  reflexes.)     The 


Fig.  17.     Cask  41.     Showing  extent  of  anesthesia. 

combination  of  symptoms,  —  paralysis  of  motion  and  of  sen- 
sation, with  disturbance  in  sphincter  control  below  a  given 
level,  is  pathognomonic  of  localized  transverse  cord  lesion, 
ordinarily  described  as  Transverse  Myelitis. 

Prognosis.  Considering  the  lapse  of  time  since  the  onset 
of  the  lesion  there  is  small  likelihood  of  material  improvement. 
Danger  to  life  depends  upon  negligence  in  physical  care. 


I06  CASE    HISTORIES    IN    NEUROLOGY. 

Treatment.  The  treatment  is  largely  palliative  and  pro- 
phylactic. Particular  care  should  be  taken  of  the  bladder 
condition  to  prevent  cystitis  and  to  obviate  its  resultant 
complications.  It  is  desirable  to  use  urotropin  to  assist  in  the 
sterilization  of  the  urine.  Duration  of  life  depends  essen- 
tially upon  the  faithful  observance  of  strict  surgical  cleanli- 
ness, since  the  disease  itself  is  not  fatal. 


SPINAL   CORD.  107 

Case  42.  H.,  a  man  of  fifty-two,  was  first  seen  in  April, 
1 910.  He  gave  the  following  history:  About  one  year  before, 
he  had  had  pain  in  the  right  leg  not  sharply  confined  to  any 
one  nerve  distribution.  This  improved  and  he  was  in  general 
well  and  able  to  work  during  the  summer  of  1909.  In  Sep- 
tember, he  had  more  pain  and  noticed  some  weakness  of  the 
legs.  Finally,  the  legs  gave  way  suddenly  so  that  he  would 
have  fallen  had  a  seat  not  been  near.  He  was  able  to  get  up, 
but  walking  was  practically  impossible  on  account  of  weakness. 
The  following  month  he  was  completely  incapacitated,  had 
considerable  general  pain  and  both  legs  were  involved.  He 
had  some  retention  of  urine  followed  by  incontinence,  but  did 
not  require  catheterization. 

Examination  showed  normal  pupils  and  no  involvement  of 
cranial  nerves.  There  was  no  headache  or  other  head  symp- 
toms. Both  arms  were  strong,  but  the  left  was  distinctly 
smaller  than  the  right  with  less  active  reflexes  and  with  con- 
siderable atrophy  of  the  small  muscles  but  without  significant 
impairment  of  function.  This  condition  had,  however, 
existed  for  many  years  and  could  not  be  brought  into  relation 
with  the  main  difficulty.  The  abdominal  reflexes  were  pres- 
ent, the  cremaster  not  obtained;  the  knee  jerks  were  lost; 
there  was  no  clonus,  Babinski,  plantar  or  Achilles.  Motion 
of  the  legs  was  possible  in  all  the  muscles,  but  weak.  There 
was  considerable  atrophy,  especially  on  the  left  side.  Sen- 
sation in  the  feet  was  somewhat  impaired  and  there  was 
considerable  loss  of  sense  of  position.  The  heart  was  negative, 
pulse  108,  blood  pressure  150.  Apart  from  the  legs,  the  gen- 
eral condition  was  excellent  and  the  patient  felt  that  he  was 
improving. 

From  that  time  on  for  about  two  months,  under  faithful 
treatment  by  massage  and  exercises,  some  definite  progress 
was  made,  so  that  he  was  able  to  get  about  to  some  degree. 
In  June,  however,  he  grew  worse  rather  suddenly  and  the  pa- 
ralysis became  almost  complete.  When  seen  in  January,  191 1 , 
he  was  in  a  decidedly  worse  condition  than  at  the  first  exami- 
nation in  April.  He  had  developed  a  bedsore  over  the  lower 
portion  of  the  spine,  and  cystitis,  controlled  fairly  well  by 
uro tropin,   had  come  on.     The  arms  were  still  unaffected. 


I08  CASE    HISTORIES    IN    NEUROLOGY. 

The  abdominal  reflexes  were  active;  the  cremaster,  the  knee 
jerks,  Achilles,  plantar  and  ankle  clonus,  as  before,  entirely 
lacking.  Motion  was  very  weak  in  both  legs,  but  somewhat 
more  so  in  the  right.  There  was  no  movement  in  the  feet; 
flexion  and  extension  at  the  knees  and  hips  very  slightly 
possible.  Abduction  and  adduction  of  the  thighs  were 
greatly  impaired.  There  was  manifest  atrophy  of  both  legs, 
masked  somewhat  by  fat  and  edema  of  the  feet.  Sensation 
of  the  legs  from  the  hips  down  was  diminished,  more  markedly 
so  in  the  feet  and  legs  than  above.  The  saddle-back  area 
and  scrotal  region  were  involved  in  the  disordered  sensation. 
There  was  no  zone  of  hyperesthesia  above  the  level  of  dimin- 
ished sensation.    There  was  constant  urinary  incontinence. 

Diagnosis.  The  nature  of  the  lesion  in  this  case  was  not 
apparent  at  the  first  examination.  It  pointed  rather  to  an 
invasion  of  the  ventral  horns  of  the  cord  in  the  lumbar  region 
of  the  nature  of  a  poliomyelitis,  since  the  disorders  of  sensa- 
tion were  extremely  slight  as  compared  with  the  motor  disa- 
bility. Later  examination,  however,  makes  it  perfectly  clear 
that  there  has  been  a  destructive  lesion  of  the  lumbar  segments 
of  the  cord  reaching  as  high  as  the  first  lumbar,  best  classified 
as  Transverse  Myelitis  not  completely  destroying  the  cord. 
The  signs  of  this  lesion  are,  disordered  sensation,  paralysis 
of  motion  and  disturbance  of  the  sphincters  below  the  point 
of  the  lesion.  The  absence  of  acute  pain  and  the  general  course 
of  the  affection  render  tumor  unlikely.  The  etiology  is 
obscure  but  presumably  depends  upon  a  vascular  condition 
possibly  induced  by  an  unknown  infection. 

Prognosis.  With  care  this  patient's  life  is  not  seriously 
threatened.  Any  laxity  on  his  part  or  on  the  part  of  those 
caring  for  him,  however,  will  easily  lead  to  bladder  compli- 
cations and  to  the  formation  of  destructive  bedsores,  either 
of  which  would  hasten  a  fatal  outcome. 

Treatment.  The  patient  has  been  faithfully  treated  by 
massage  and  electricity  with  a  certain  amelioration  of  his 
condition.  Scrupulous  care  and  cleanliness  are  the  essential 
matters  of  importance.  The  damage  to  the  cord  being  irre- 
mediable, the  treatment  resolves  itself  Into  means  of  preven- 
tion of  further  disaster  rather  than  an  attempt  at  cure. 


SPINAL    CORD.  109 

Case  43.  I.,  a  man  of  forty-four,  six  months  before  being 
seen  had  fallen  about  twenty  feet,  presumably  striking  on 
his  back.  He  did  not  lose  consciousness.  His  right  leg 
was  particularly  hurt  and  he  supposed  he  had  broken  his  hip. 
For  three  months  succeeding  the  fall  he  had  complete  urinary 
retention,  which  was  then  succeeded  by  incontinence.  The 
bowels  were  constipated.  For  two  months  he  had  had  no 
severe  pain.  At  the  end  of  that  time,  however,  he  began  to 
suffer  constantly  from  pain  through  the  right  side.  He  had 
had  a  bedsore  for  three  months. 

Examination  showed  both  knee  jerks  lost,  no  Achilles,  no 
plantar,  no  clonus.  The  right  leg  was  completely  flaccid,  with 
no  motion  whatever  possible.  There  was  some  slight  move- 
ment of  the  left  thigh  and  leg  but  none  of  the  foot.  The  toes 
were  held  in  sharp  plantar  flexion.  The  cremasteric  reflex 
was  lacking  on  the  right,  active  on  the  left.  The  abdominal 
reflex  w^as  more  active  on  the  right  than  on  the  left.  There  was 
some  deformity  of  the  back  in  the  lower  thoracic  and  lumbar 
region.  The  sensory  disturbance  in  the  legs  was  as  follows: 
On  the  right,  sensation  was  completely  lost  below  the  knee, 
extending  upward  to  about  the  rim  of  the  pelvis  and  to  within 
an  inch  or  two  of  the  umbilicus.  There  was  spontaneous 
pain  in  the  left  thigh.  The  left  buttock  was  also  numb, 
the  right  less  so.  The  left  leg  showed  complete  loss  of  sensa- 
tion in  the  foot,  slight  loss  on  the  inner  side  of  the  leg,  partial 
loss  on  the  outer  side  extending  up  as  far  as  the  knee.  The 
penis  and  scrotum  took  part  in  the  sensory  disturbance. 

Diagnosis.  There  was  in  this  case  presumably  a  Fracture 
of  the  Spine  in  the  lower  thoracic  region,  leading  to  a  definite 
destruction  of  the  cord  on  the  right  side  and  much  less  serious 
damage  on  the  left.  The  pain  in  the  right  thigh  is  to  be  ex- 
plained by  pressure  on  sensory  nerve  roots,  possibly  through 
splintered  bone  but  more  probably  through  hemorrhagic 
exudate  at  the  level  of  the  lesion.  The  fact  that  the  pain  grew 
worse  two  months  after  the  accident  is  presumably  due  to  the 
constriction  of  the  nerves  by  the  organized  blood  clot.  The 
absent  knee  jerks  must  be  explained  by  the  destruction 
of  that  segment  of  the  lumbar  cord  through  which  the  reflex 
arc  passes. 


no  CASE    HISTORIES    IN    NEUROLOGY. 

Prognosis.  Improvement  but  not  recovery  is  to  be  ex- 
pected. 

Treatment.  Exploratory  operation  is  justified  if  the  pain 
persists  and  is  severe.  It  is  not  to  be  supposed  that  a  lami- 
nectomy would  have  any  effect  in  relieving  the  long-standing 
degeneration  which  the  cord  evidently  has  undergone. 


SPINAL   CORD.  Ill 

Case  44.  S.,  a  fisherman,  thirty-nine  years  old,  on  October 
14,  1909,  struck  his  head  violently  against  the  boom  of  his  ves- 
sel as  he  was  passing  under.  He  was  thrown  to  the  deck, 
striking  on  the  back  of  his  head.  His  tarpaulin  mitigated 
somewhat  the  severity  of  the  blow.  He  did  not  lose  conscious- 
ness and  was  able  to  speak,  but  was  unable  to  move  either 
his  arms  or  legs  and  had  a  sensation  of  numbness  over  his 
body  and  extremities.  In  about  twenty  minutes  sensation 
began  to  return  in  the  left  index  finger,  then  in  the  left  hand 
and  arm.  The  following  day  his  right  leg  began  to  recover, 
but  the  right  arm  and  the  left  leg  were  still,  when  seen  Feb- 
ruary I,  1910,  definitely  affected.  The  left  arm  and  the  right 
leg  had  practically  recovered  but  he  had  noticed  that  the  arm 
"  went  to  sleep  easily  in  the  afternoon."  There  had  also  been 
general  improvement  in  strength.  There  had  been  no  urinary 
disorder,  but  he  had  been  more  constipated  than  before  the 
accident.  There  had  been  no  definite  headache  and  no  vomit- 
ing, even  immediately  after  the  injury.  He  had  not  been  able 
to  return  to  his  boat  on  account  of  general  nervousness. 
He  had  noticed  that  on  standing  with  the  head  bent  forward 
he  experienced  a  sensation  as  of  electricity  passing  through 
him  over  the  chest  and  from  the  elbows  to  the  tips  of  the  fin- 
gers. On  bending  his  head  backward  he  had  a  similar  sen- 
sation. He  had  also  had  considerable  pain  between  the 
shoulders,  especially  when  lying  on  his  back.  There  was  some 
pain  also  over  a  small  area  on  the  left  abdomen.  His  feet 
had  been  cold,  but  this  was  associated  with  burning  sensa- 
tions, and  the  left  foot  had  swollen  somewhat  at  night. 

Examination  showed  the  following  conditions:  The  pupils 
were  normal  and  the  cranial  nerves  uninvolved.  The  arms 
were  both  somewhat  weak  but  more  on  the  right  than  on  the 
left.  The  wrist  and  elbow  jerks  were  very  active.  There  was 
diminished  sensation  on  the  outer  side  of  the  arms.  The 
disturbance  was  greater  on  the  right  than  on  the  left.  The 
legs  were  less  affected,  but  the  knee  jerks  were  very  much 
increased ;  there  was  double  ankle  clonus  rather  more  marked 
on  the  right  than  on  the  left;  both  Achilles  reflexes  were  ac- 
tive, but  there  was  a  slight  normal  plantar  reflex.  Sensation 
in  the  feet  was  unimpaired.     There  was  no  Romberg  sign. 


112  CASE   HISTORIES    IN    NEUROLOGY. 

The  left  leg  was  much  weaker  than  the  right,  the  right  being 
essentially  normal. 

Diagnosis.  In  this  case,  the  injury  was  evidently  by 
contre-coHp,  as  often  seen  in  diving  accidents.  Immediately 
after  the  blow  the  entire  spinal  cord  from  a  point  in  the  cer- 
vical region  temporarily  lost  its  function.  The  subsequent 
course  and  outcome,  however,  demonstrated  that  the  lesion 
was  not  transverse,  and  that  it  affected  incompletely  a  region 
of  the  cord  at  the  level  of  the  fifth  cervical  segment,  as  shown 
by  the  final  areas  of  disturbed  sensibility.  The  Increase  of 
deep  reflexes  In  the  legs  shows  that  the  Injury  to  the  cord  had 
distinctly  invaded  the  pyramidal  tracts,  leaving  intact  the 
sensory  fibers  from  the  legs  and  body.  Sharp  localization 
of  sensory  disturbance  in  the  arms  makes  it  probable  that  the 
nerve  roots  were  involved  in  the  process  rather  than  the  cord 
itself. 

Prognosis.  The  outcome  in  this  case  has  been  unex- 
pectedly favorable.  It  Is  evident  that  the  Injury  is  far  less 
severe  than  was  at  first  thought  probable.  Recovery  is, 
however,  not  likely  to  be  entirely  complete. 

Treatment.  Natural  processes  are  most  efficacious  In 
such  a  case  as  this.  Care  should  be  taken  not  to  over-exert 
the  damaged  parts  of  the  body  and  to  assist  In  their  restora- 
tion by  massage  and  other  rnechanical  means  of  treatment. 


SPINAL   CORD.  113 

Case  45.  T.,  sixteen  years  old,  was  shot  by  a  3S-caliber  re- 
volver at  a  range  of  about  two  feet,  the  bullet  striking  about 
one  inch  above  the  sternum  slightly  to  the  right  of  the  median 
line  between  the  insertions  of  the  sterno-mastoid  muscles. 
The  exit  of  the  bullet  was  half  an  inch  above  the  upper  sur- 
face of  the  scapula,  a  quarter  of  an  inch  to  the  left  of  the 
median  line,  having  passed  through  the  vertebral  column. 
The  boy  was  not  unconscious  and  had  no  pain  at  any  time. 
He  fell  to  the  floor  with  immediate  and  complete  loss  of  con- 
trol of  the  legs  and  of  the  bladder,  together  with  loss  of  sen- 
sation in  the  lower  part  of  the  body  and  in  the  legs.  There 
was  rapid  improvement  in  sphincter  control  and  in  sensation, 
but  the  paralysis  of  the  legs  persisted.  There  was  at  no  time 
any  temperature. 

Examination  showed  widely  dilated  but  normally  reacting 
pupils  and  unafTected  cranial  nerves.  There  was  no  disturb- 
ance of  motion  or  sensation  in  the  arms  beyond  the  fact  that 
the  left  hand  was  constantly  closed.  There  was  numbness 
in  the  right  axilla  and  below  but  the  sensation  was  not  lost. 
There  was  less,  but  still  definite,  disturbance  on  the  left  side. 
At  the  level  of  the  crests  of  the  ilia,  reaching  anteriorly  to  about 
the  level  of  the  umbilicus,  sensation  was  practically  lacking. 
There  were  no  abdominal  or  epigastric  reflexes.  In  the  right 
leg  there  was  sensation  in  the  thigh  to  pain  stimulation,  but 
not  below  the  knee.  In  the  left  leg  there  was  practically 
no  sensibility  excepting  a  doubtful  area  about  the  knee. 
There  was  no  voluntary  movement  of  the  legs.  The  knee 
jerks  were,  however,  normally  present;  the  Achilles  jerks  were 
active;  there  was  no  plantar  reflex  and  no  clonus.  The  back 
was  slightly  sensitive,  but  pricks  felt  as  if  a  "  cloth  were  over 
it."    The  skin  was  somewhat  broken  over  the  left  buttock. 

Diagnosis.  The  bullet  in  its  passage  through  the  spinal 
column  evidently  injured  the  cord  at  the  lower  cervical 
level  without  completely  destroying  it,  as  shown  by  the  fact 
that  sensation  was  still  present  below  the  point  of  the  lesion, 
although  greatly  altered.  It  is  evident  that  the  dorsal  col- 
umns, particularly  in  the  median  portion,  were  more  involved 
than  other  portions  of  the  sensory  tracts,  and  that  the  pyrami- 
dal  tracts   were   invaded   to  a   considerable    degree.      It  is 


114  CASE   HISTORIES    IN    NEUROLOGY. 

of  interest  that  the  knee  jerks  remained  essentially  normal 
under  these  conditions. 

Prognosis.  A  permanent  disability  of  the  legs  is  sure  to 
persist. 

Treatment.  The  treatment,  as  described  under  Cases 
41  and  42,  is  dependent  upon  a  clear  recognition  of  the  danger 
of  bedsores  and  of  bladder  complications  in  conditions  of 
body  and  leg  anesthesia. 


SPINAL   CORD. 


115 


Case  46.  O.,  a  young  woman  athlete,  fell  thirty  feet  from 
a  trapeze  into  a  net,  bending  her  head  violently  forward 
in  such  a  way  that  there  was  a  fracture  of  the  spine  in  the 
region  of  the  sixth  cervical  segment.  Complete  paralysis 
of  motion,  sensation  and  of  the  sphincters  below  the  point 
of  injury  occurred  at  once.  A  laminec- 
tomy was  done,  disclosing  a  crushed  cord 
without  external  hemorrhage.  Death  re- 
sulted on  the  third  day. 

Autopsy.  Macroscopic  examination  of 
the  cord  showed  a  slight  blue  discoloration, 
one  centimeter  in  length,  between  the  sixth 
and  seventh  cervical  segments ;  the  discol- 
oration was  more  marked  on  the  ventral 
side.  There  was  not  the  slightest  indica- 
tion either  of  extra-  or  intra-dural  hem- 
orrhage. A  transverse  section  at  the  point 
of  greatest  injury  showed  hemorrhagic 
softening  involving  the  whole  area  of  the 
cord,  excepting  a  small  portion  of  the 
dorsal  white  tracts.  Above  this  point, 
^tending  through  four  segments,  was  a 
tubular  hemorrhage  in  the  dorsal  white 
matter,  most  marked  in  the  third  segment. 
Below  the  area  of  softening,  there  was  con- 
siderable hemorrhage  within  the  substance 
of  the  cord  for  a  distance  of  several  centi- 
meters. Another  tubular  hemorrhage, 
similar  in  position  and  extent  to  the  one 
in  the  upper  cervical  region,  was  trace- 
able through  the  second,  third  and  fourth 
thoracic  segments.  Microscopic  exami-  Sn^JeT?e"vLtt)"hoick: 
nation  verified  the  appearances  as  seen  in 
gross.  The  gray  and  the  white  matter  were  not  to  be  dis- 
tinguished from  each  other;  the  myelin  was  in  part  stain- 
able  by  the  Weigert  method  but  showed  much  evidence  of 
disintegration.  There  was  fresh  hemorrhage  throughout  the 
cord  but  none  whatever  externally. 

Diagnosis.      This   case   illustrates   a   complete   transverse 


Fig.  18.     Case  46. 
Showing   damage   to  cord  at 


Il6  CASE   HISTORIES    IN    NEUROLOGY. 

lesion  of  the  cord,  usually,  as  in  this  case,  quickly  fatal.  The 
extent  of  the  lesion  beyond  the  main  point  of  injury  is  impor- 
tant as  showing  the  effects  at  a  distance  of  violence  to  any  one 
part  of  the  central  ner\'Ous  system,  and  also  as  explanatory 
in  certain  cases  of  symptoms  difficult  to  interpret  by  a  single 
focal  lesion.  The  futility  of  surgical  interference  in  such  cases 
of  complete  destruction  of  the  cord  is  evident.  The  hem- 
orrhage, as  in  this  instance,  is  almost  invariably  within  the 
substance  of  the  cord,  rather  than  subdural.  Even  if  a  sub- 
dural clot  can  be  removed,  the  accompanying  destruction 
of  the  cord  renders  the  operation  wholly  inefficacious.  Ex- 
treme pain  or  evidence  of  fractured  laminae  justify  explora- 
tion. Otherwise,  in  most  cases  of  damage  to  the  cord,  operation 
should  not  be  undertaken,  first  because  it  can  accomplish 
nothing,  and  secondly  because  it  leads  to  an  added  shock 
which  is  already  great.  This  is  especially  true  of  lesions  in 
the  cen^ical  region. 

Prognosis.  The  outcome  of  destructive  lesions  in  the  cer- 
vical region  of  the  cord  is  almost  invariably  fatal,  for  the  reason 
that  the  nen^es  of  respiration  are  involved,  particularly  the 
phrenic  to  the  diaphragm,  derived  from  the  mid-cerv4cal 
region. 

Treatment.  Treatment  is  in  general  unavailing.  (See 
remarks  under  Diagnosis.) 


SPINAL   CORD.  117 

Case  47.  R.  was  admitted  to  a  hospital,  September  2,  1896, 
at  the  age  of  forty-nine.  Her  family  and  previous  history 
have  no  bearing  on  the  present  situation.  The  story,  although 
apparently  contradictory  in  certain  respects,  is  essentially 
as  follows: 

In  July,  1894,  she  caught  her  foot  in  her  skirt,  as  she 
was  going  up  some  steps,  and  was  thrown  violently  backward 
on  her  spine,  striking  on  the  lower  portion,  and  being  uncon- 
scious for  a  half-hour.  On  recovering  consciousness,  she  found 
herself  paralyzed,  both  in  arms  and  legs.  She  was  taken 
to  a  hospital,  where  an  operation  was  suggested,  but  declined. 
Recovery  of  the  upper  extremities  took  place  gradually,  but 
the  legs  remained  paralyzed,  both  as  regards  sensation  and 
motion,  together  with  paralysis  of  the  bladder  and  rectum. 
This  latter  condition  continued  for  about  two  months, 
and  then  gradually  improved.  In  two  or  three  weeks  after 
the  accident,  the  sensation  began  to  return  in  the  right  hand 
and  arm;  then  in  the  left,  but  for  a  long  time  incompletely. 
There  was  also  gradual  improvement  in  the  movement  of 
the  left  lower  extremity,  but  disturbance  of  sensation  per- 
sisted. It  was  at  once  noted  that  sensation  was  preserved 
in  the  right  lower  extremity,  but  that  the  loss  of  motion  was 
there  practically  complete.  A  note  made  September  2,  1896, 
states  that  the  right  arm  had  perfect  sensation  and  motion; 
that  the  bladder  function  was  still  disturbed,  but  that  the  gen- 
eral condition  of  the  patient  was  good. 

Physical  examination,  February  i,  1897,  was  as  follows: 
Except  for  slight  irregularity  of  the  pupils,  the  eyes  were  nor- 
mal. Other  cranial  nerves  were  not  affected.  Movements 
of  both  arms  were  unimpaired  and  without  alteration  in 
reflexes.  Abdominal  and  epigastric  reflexes  were  lacking. 
There  was  a  minimum  amount  of  movement  in  the  various 
joints  of  the  right  leg,  with  increased  knee  jerks.  The  improve- 
ment since  the  accident,  both  as  regards  general  condition 
and  special  paralyses,  was  very  definite. 

On  May  2,  1899,  the  patient  was  in  essentially  the  same 
condition,  except  that  she  had  regained  complete  use  of  her 
body  and  arms.  She  had,  however,  not  been  able  to  walk, 
and  the  paralysis  of  the  right  leg  has  remained  essentially 


Il8  CASE    HISTORIES    IN    NEUROLOGY. 

unchanged.  Lancinating  pains  in  the  sciatic  region  of  both 
legs,  which  had  previously  been  an  annoyance,  had  gradually 
disappeared.  The  loss  of  sensation  in  the  left  leg  was  definite 
at  this  time,  as  it  has  remained  since.  There  was  still  some 
incontinence  of  urine. 

The  patient  was  examined  at  various  times  during  the  ten 
or  more  years  of  her  stay  at  the  hospital,  with  essentially 
the  same  result.  Beyond  considerable  adiposity,  she  showed 
no  abnormality  outside  of  the  nen''Ous  system.  The  last 
thorough  examination  was  made  on  the  22d  of  December,  1905, 
and  gave  the  following  results: 

Motion,  legs  and  feet:  Right,  active  movements  im- 
possible at  knee  ankle  and  toes,  beyond  a  possible  very 
slight  flexion  of  the  toes.  On  the  left,  movements  at  knee, 
ankle  and  toes  perfectly  normal,  and  with  excellent 
strength.  The  right  knee  jerk  extremely  active;  the  left 
very  much  less  so.  Ankle  clonus  distinctly  brought  out  on 
both  sides,  but  stronger  and  more  persistent  on  the  right. 
The  Babinski  sign  definitely  present  on  both  sides,  but  more 
easily  elicited  on  the  right.  The  Achilles  reflex  not  definite 
on  either  side.  Front  tap,  both  right  and  left,  produced 
slight  flexion  of  the  great  toes.  There  were  no  spastic  con- 
tractures. All  passive  movements  possible  in  both  legs, 
although  the  right  leg  was  slightly  rigid. 

Sensation:  Pin  prick  felt  much  more  sharply  on  the  right 
foot  and  leg  than  on  the  left,  with  essentially  normal  motion. 
On  the  left,  the  sensation  was  described  as  "  numb,"  a  de- 
scription which  applies  to  the  whole  left  leg.  The  temperature 
tests  on  the  right  leg  were  invariably  correctly  interpreted. 
On  the  left  it  was  Impossible  for  the  patient  to  differentiate 
between  heat  and  cold.  Simple  contact  was  felt  about  equally 
on  both  legs,  absorbent  cotton  being  used  for  the  test.  The 
same  condition  existed  well  up  on  to  the  trunk.  No  abdominal 
reflexes  were  obtainable.  The  patient  stated  that  she  felt 
objects  somewhat  better  in  the  right  hand  than  In  the  left, 
which  was  apparently  the  fact.  The  arm  reflexes  and  strength 
of  the  arms  were  unimpaired,  and  the  cranial  nerves  showed 
no  abnormality. 

Diagnosis.    An  autopsy  was  not  obtainable  in  this  case,  but 


SPINAL   CORD. 


119 


the  symptoms  and  the  signs  clearly  show  that  the  patient 
suffered  a  partial  destruction  of  the  cord,  particularly  limited 
to  one  side,  presumably  due  to  hemorrhage  or  softening  in  the 
thoracic  region.  In  favor  of  this  hypothesis  is  the  fact 
that  she  had  a  paralysis  of  the  lower  extremities  of 
the  Brown-Sequard 
type,  —  namely,  paraly- 
sis of  motion  more 
marked  on  one  side  and 
paralysis  of  sensation 
more  marked  on  the 
other,  with  a  preserva- 
tion of  the  sense  of  con- 
tact. The  explanation 
of  this  symptom-com- 
plex is  found  in  the  cross- 
ing of  the  various  fibers 
subserving  motion  and 
sensation  in  its  several 
forms  as  illustrated  by 
the  accompanying  dia- 
gram. 

Prognosis.  The  pa- 
tient lived  for  many  years 
with  relatively  small  discomfort,  except  for  the  fact  that  she 
was  very  stout  and  locomotion  was  impossible.  Death  finally 
resulted  from  intercurrent  disease. 

Treatment.  Surgical  intervention  shortly  after  the  onset 
of  the  paralysis  was  refused  by  the  patient,  no  doubt  wisely, 
as  the  event  proved.  At  first  she  improved  rapidly  and  later 
more  slowly,  but  it  is  not  probable  that  an  operation  could 
in  any  way  have  hastened  this  process.  She  was  nursed  with 
care,  but  beyond  this  her  treatment  was  merely  symptomatic. 


Fig.  ig.     Case  47. 

M,  motility,  uncrossed  ;  PT,  pain  and  temperature, 
crossed  ;  C,  contact,  presumably  partially  crossed,  here 
represented  as  uncrossed.  A  hemisection  of  the  cord  at  X 
will  therefore  lead  to  paralysis  of  motion  in  the  same  side, 
and  to  loss  of  pain  and  temperature  sense  on  the  opposite 
side.  Sense  of  contact  and  joint  sensibility  is  lost  in  a 
measure  at  least  on  the  same  side  as  the  lesion.  The 
symptom-complex  is  rarely  completely  developed. 


120  CASE    HISTORIES    IN    NEUROLOGY. 

Case  48.  I.,  age  thirty-five,  a  laborer,  was  admitted  to 
a  hospital,  December  8,  1898.  There  was  nothing  in  the  fam- 
ily history  bearing  on  his  present  condition.  He  remembered 
no  previous  illness  of  significance  beyond  the  fact  that  he  was 
at  one  time  overcome  by  the  heat  while  at  work  in  a  foundry. 
He  had  no  obtainable  venereal  history,  and  was  moderate 
in  the  use  of  alcohol  and  tobacco. 

October  7,  1888,  he  fell  eighteen  feet  from  a  wharf ,  striking 
on  his  back  in  about  one  foot  of  water.  He  was  able  to  get  on 
his  feet  and  walk  out  of  the  water  to  a  considerable  distance, 
when  he  fell  on  his  knees.  From  that  time  on  he  had  prac- 
tically no  use  of  his  legs.  He  remained  in  bed  for  several  days 
unable  to  move  his  legs  and  with  incontinence  of  urine  and 
feces.  He  also  lost  sensation  in  his  legs  at  this  time.  He  had 
incontinence  of  urine  and  partial  incontinence  of  feces,  and 
complained  of  severe  dull  pain  through  his  back.  There  was 
no  improvement  in  motion  or  sensation.  He  had  a  feeling 
of  constriction  about  his  body.  After  a  certain  amount 
of  general  Improvement,  at  the  end  of  about  eight  months 
he  was  transferred  to  a  hospital  for  chronic  disease,  where 
he  remained  for  seven  years.  During  this  period  sensation 
In  the  legs  returned,  so  that  he  was  able  to  recognize  touch; 
the  pain  in  the  back  also  Improved,  and  he  was  finally  able 
to  get  about  on  crutches.  While  in  the  hospital  he  had  two 
illnesses  of  unknown  character,  during  which  he  fell  off 
very  materially  in  weight. 

Physical  examination  on  January  6,  1899,  showed  move- 
ment at  the  hip  and  knees  possible  but  weaker  than  normal. 
Movements  of  the  toes  were  also  possible  but  weak.  The 
knee  jerks  were  increased  but  there  was  no  clonus  on  either 
side.  The  plantar  reflexes  were  present;  the  cremaster, 
abdominal  and  epigastric  reflexes  lacking.  Examination 
of  sensation  at  this  time  showed  areas  of  partial  anesthesia 
and  hyperesthesia  from  about  the  seventh  thoracic  segment 
downward.  The  patient  died  May  12,  1899,  without  material 
change  in  his  condition. 

The  autopsy  showed,  external  to  the  cord,  a  mass  of  highly 
organized  tissue,  presumably  the  ultimate  outcome  of  a  very 
old  blood  clot.      The  cord  Itself   was   damaged    practically 


SPINAL    CORD.  121 

beyond  recognition,  although  the  symptoms  even  up  to  the 
end  of  the  patient's  hfe  showed  the  possibiHty  of  a  certain 
amount  of  conduction. 

Diagnosis.  The  striking  feature  of  this  case  Hes  in  the  fact 
that  after  the  fall  the  patient  was  able  to  get  to  his  feet 
and  walk  a  considerable  distance  before  falling  with  a  rapidly 
supervening  complete  paralysis  of  the  legs.  This  unusual  his- 
tory suggests  the  possibility  of  a  Hemorrhage  which  did  not 
at  once  attain  sufficient  extent  to  destroy  the  cord.  The 
analogy  to  the  period  of  consciousness  following  meningeal 
hemorrhage  is  striking  and  suggestive. 

Prognosis.  The  patient  lived  eleven  years,  a  large  part  of 
that  time  being  spent  in  hospitals.  He  was  never  useful  during 
this  long  period,  but  at  one  time  was  able  to  get  about  to  some 
extent  with  a  skilfully  devised  apparatus ;  he  was  also  able 
to  use  crutches. 

Treatment.  In  this  case  it  is  probable,  had  an  exploratory 
laparotomy  been  done  at  once,  that  a  very  considerable  relief 
might  have  been  secured.  Hemorrhage  extra-  or  sub-dural 
is,  however,  in  these  cases  so  unusual  an  occurrence  that 
immediate  surgery  is  usually  not  demanded. 


122  CASE   HISTORIES    IN    NEUROLOGY. 

Case  49.  E.  was  referred  by  an  ophthalmologist  for  a 
slight  twitching  of  the  face  muscles,  flushing  of  the  left  side 
of  the  face  and  tingling  sensations  in  the  tongue  on  the  right 
side.  The  eyes  were  reported  by  him  normal,  except  for 
fibrillary  twitching  of  the  lower  left  lid.  The  pupils  were 
normal,  as  were  the  muscle  balance,  \ision  and  the  fundus. 
She  was  twenty-five  years  old,  unmarried,  and  was  leading 
a  somewhat  arduous  life  as  a  nurse.  She  was  first  seen  Decem- 
ber II,  1909,  with  the  complaint  that  for  five  or  six  weeks  she 
had  noticed  twitching  of  the  muscles  under  the  left  eye,  which 
she  thought  was  extending  somewhat  to  the  muscles  below  the 
mouth.  She  had  much  cause  for  anxiety  apart  from  her  work ; 
her  sleep  had  been  interrupted;  she  felt  herself  tired.  Her 
appetite,  bowel  action  and  menstruation  were  normal. 
She  was  under  the  impression  that  the  twitching  was  more 
marked  when  she  was  tired  and  overw^orked.  Physical  ex- 
amination showed  no  abnormalit}^  beyond  the  twitching  move- 
ments already  referred  to  and  a  possible  slight  left  facial 
paresis.  She  was  somewhat  emotional,  for  which  there  seemed 
adequate  cause.  There  was  no  sufificlent  evidence  to  indicate 
a  structural  disease  of  the  nervous  system. 

She  was  again  seen  one  year  later.  She  had  given  up  her 
w^ork  and  had  had  many  symptoms,  among  them  brief 
attacks  of  deafness,  marked  speech  disorder,  slight  Jack- 
sonian  attacks,  facial  paralysis.  None  of  these  were  persist- 
ent. Vision  had  constantly  and  steadily  failed  to  the  point 
that  she  was  able  to  see  very  little  distinctly,  although  still 
able  to  count  fingers  if  brought  near  her  eyes. 

Examination  showed  the  following  conditions.  Pupils 
wide,  imperfect  light  response,  better  on  the  right  than  on 
the  left;  no  well-defined  nystagmus.  The  optic  disks  were 
very  pale  In  both  eyes  but  without  marked  alteration  of  the 
vessels.  There  was  no  definite  pallor  of  the  temporal  halves 
of  the  disks  as  compared  with  the  nasal.  Hearing  (Rinne 
test)  normal  in  both  ears ;  tongue  protruded  straight  without 
definite  tremor;  other  cranial  nerves  normal  with  the  possible 
exception  of  a  slight  facial  palsy  to  which  allusion  has  already 
been  made.  The  arm  reflexes  were  all  active;  objective  sen- 
sation was  somewhat  blunted,  especially  In  the  right  hand ; 


SPINAL   CORD.  123 

there  was  an  extreme  degree  of  ataxic  tremor  of  the  right  arm 
and  hand,  less  marked  on  the  left.  The  knee  jerks  were  very 
active;  Achilles  obtained  on  both  sides;  Bablnski  marked  on 
the  left,  strongly  Indicated  on  the  right;  ankle  clonus  sug- 
gested but  not  definitely  obtained  on  both  sides;  objective 
sensation  of  the  feet  was  well  preserved  but  with  distinct  loss 
of  sense  of  position  of  the  toes.  She  was  unable  to  walk. 
While  sitting  in  her  chair  there  was  absolutely  no  tremor; 
on  attempted  movement,  extreme  ataxia  developed,  particu- 
larly In  the  right  arm,  to  the  extent  that  it  was  impossible  for 
her  to  feed  herself  or  do  anything  definite  with  the  hand. 
There  was  also  considerable  tremor  of  the  head  and  of  the  legs, 
when  moved.  Her  speech  was  distinctly  scanning  in  type, 
but  was  said  at  times  to  have  been  worse  than  at  this  exami- 
nation. There  was  no  definite  history  of  forced  laughter  or 
weeping;  mentally  she  was  clear  but  showed  considerable 
euphoria;  her  manner  was  decidedly  more  cheerful  than  at 
the  examination  a  year  previously,  before  definite  symptoms 
had  developed.  The  heart  was  normal;  blood  pressure  no, 
and  pulse  of  normal  rate  and  rhythm. 

Diagnosis.  This  is  undoubtedly  a  case  of  Multiple  (dis- 
seminated) Sclerosis.  The  signs  of  tremor  of  the  Intention 
type,  scanning  speech,  sense  of  well-being,  abnormally  active 
deep  reflexes,  together  with  the  transient  character  of  many 
of  the  symptoms,  and  progressive  atrophy  of  the  optic  nerves 
render  this  diagnosis  certain.  The  chief  Interest  of  the  case 
lies  In  the  fact  that,  only  one  year  before,  none  of  these  signs 
was  evident  and  no  other  diagnosis  at  that  time  appeared 
justified  than  facial  spasm  on  the  basis  of  general  nervous 
exhaustion. 

Prognosis.  The  extreme  rapidity  of  the  development  of 
serious  symptoms  renders  the  outlook  for  life  doubtful. 
It  Is  not  probable  that  the  patient  will  live  more  than  two 
•  years.  It  should,  however,  be  remembered  that  long  remis- 
sions of  symptoms  are  frequent,  If  not  characteristic,  in  this 
disease.  Complete  blindness  Is  sure  to  supervene  In  a  rela- 
tively short  time. 

Treatment.    The  treatment  is  palliative  merely. 


124  CASE    HISTORIES    IN    NEUROLOGY. 

Case  50.  S.,  thirty-six  years  old,  widow,  born  in  Ireland, 
was  admitted  to  a  hospital  December  5,  1898.  The  family 
history  was  not  important.  The  patient  had  always  been 
well;  she  had  had  two  children,  both  healthy,  but  who  have 
since  died,  and  one  miscarriage  said  to  have  been  the  result 
of  falling  downstairs.  She  denied  venereal  disease  and  gave 
no  definite  history  of  infectious  disease;  she  had  taken  alcohol 
in  excess,  chiefly  beer.  About  a  year  before  entrance  to  the 
hospital  she  noticed  an  increasing  weakness  of  the  legs; 
also  unusual  "  motor  nerv^ousness  " ;  she  was  told  by  a  friend 
that  her  face  did  not  look  natural,  which  she  verified  by 
looking  into  the  mirror  and  finding  that  her  face  was  drawn 
to  one  side;  she  had  had  no  pain  and  did  not  know  of  this 
change  until  told.  In  two  weeks  her  symptoms  had  entirely 
disappeared,  and  they  did  not  return  until  eight  months 
pre\'ious  to  her  admission,  when  she  says  that  she  caught 
cold ;  her  right  arm  and  leg  became  weaker,  and  she  found  she 
could  not  do  her  work  satisfactorily,  which  was  waiting  on 
table. 

Notes  made  during  the  following  months  show  that  the 
reflexes  were  increased ;  that  she  had  the  Babinski  sign ;  that 
there  was  slight  nystagmus  of  both  eyes;  that  her  speech 
was  slow  and  scanning;  that  there  was  much  spasticity  of 
the  lower  extremities,  but  without  definite  disorder  of  sensi- 
bility. A  year  later  she  had  increasing  difficulty  in  walking 
and  often  fell;  tremor  of  hands  at  times  prevented  her  from 
grasping  a  support,  and  she  gradually  became  confined  to  her 
chair.  Beyond  the  general  symptoms  noted,  she  was  well; 
her  appetite  was  good;  bowels  regular,  sleep  satisfactory, 
and  she  made  no  complaints. 

October  30,  1901,  she  was  unable  to  feed  herself  with  her 
right  hand  because  of  tremor,  but  she  could  use  her  left. 
Careful  examination  at  this  time  showed  no  disorder  of 
sensibility. 

A  detailed  examination  made  July  10,  1902,  was  as  follows: 
As  the  patient  sat  in  a  chair  with  head  resting,  there  was 
practically  no  tremor  either  of  head  or  extremities;  on  raising 
the  head  a  marked  tremor,  coarse  in  character,  was  apparent. 
The  patient  naturally  sat  with  her  head  supported;    on  at- 


SPINAL   CORD.  125 

tempting  to  make  any  Intended  movement  a  very  marked 
tremor  manifested  itself,  very  much  more  pronounced  on  the 
right  side  than  on  the  left;  this  tremor  affected  not  only  the 
arm  in  use  but  also  the  entire  body  and  head;  for  example, 
an  attempt  to  button  a  large  button  with  the  left  hand  was 
accomplished  with  difficulty  and  considerable  tremor;  the 
same  action  with  the  right  hand  was  absolutely  impossible, 
owing  to  the  increasing  violence  of  the  tremor;  an  attempt 
to  write,  even  with  the  left  hand,  was  entirely  impossible, 
the  whole  body  being  thrown  into  a  violent  tremor.  An 
effort  to  make  definite  movements  with  the  legs  while  in 
a  sitting  position  was  carried  out  with  apparent  weakness 
and  very  imperfectly,  owing  to  the  tremor;  it  was  also  impos- 
sible for  her  to  stand  alone;  the  attempt  to  rise  from  a  sitting 
posture  with  support  was  effected  only  with  a  violent  exacer- 
bation of  the  tremor.  The  patient  did  not  walk  or  attempt 
to  get  about  without  assistance.  The  speech  was  of  a  per- 
fectly typical  scanning  character.  There  was  no  oscillation 
of  the  eyes  on  direct  fixation  in  a  straight  line;  on  attempting 
to  follow  the  finger  to  one  or  the  other  side  a  marked  oscilla- 
tion developed,  with  inability  to  fix  the  eyes  for  any  length 
of  time;  the  pupils  were  equal  in  size.  There  was  slight 
asymmetry  of  the  face,  but  no  paralysis  of  any  of  the  cranial 
nerves.  Watch  tick  was  heard  better  on  the  right  than  on 
the  left;  on  the  right  at  a  distance  of  about  two  feet,  on  the 
left,  three  or  four  inches,  approximately.  Muscles  were  well 
formed  and  sufficiently  voluminous,  with  no  evidence  what- 
ever of  atrophy ;  except  for  the  tremor,  the  active  and  passive 
movements  of  the  arms  were  free,  and  the  hand  grasp  on 
both  sides  was  of  a  fair  degree  of  strength ;  there  was  no  pa- 
ralysis of  the  legs,  the  movements  being  effected  with  slight 
appearance  of  weakness,  but  otherwise  normally,  apart 
'from  the  tremor.  The  knee  jerks  were  much  Increased  and 
there  was  marked  ankle  clonus  on  both  sides;  also  definite 
Babinski  on  both  sides;  abdominal  and  epigastric  reflexes 
absent;  slight  increase  in  deep  reflexes  of  the  arms.  Light 
touch  and  pin  prick  felt  apparently  over  the  body  and  limbs; 
patient  made  no  complaint  of  numbness,  pain  or  other  dis- 
turbance of  sensation. 


126  CASE   HISTORIES    IN    NEUROLOGY. 

The  heart  and  lungs  were  normal.  The  bowels  were  regu- 
lar; appetite  good  and  sleep  undisturbed;  no  disturbance 
of  micturition.  The  mental  state  on  the  whole  was  normal, 
but  the  patient  possibly  showed  some  defect  in  memory  and 
a  slightly  abnormal  sense  of  well-being. 

August  6,  1902,  the  condition  was  not  much  changed; 
she  suffered  no  pain,  but  was  heavily  handicapped  by  tremor, 
since  she  could  not  comb  her  hair,  feed  herself,  or  even  pick 
up  anything  without  great  difficulty.  She  was  barely  able 
to  raise  herself  from  her  chair. 

Examination,  April  9,  1903,  was  as  follows:  Feet  very  cold 
and  somewhat  cyanotic;  ankle  clonus  on  both  sides;  very 
active  Achilles  reflex  on  both  sides,  which  throws  the  feet 
into  clonus;  front  tap  on  the  left  very  marked,  absent  on  the 
right;  Babinski  reflex  b}^  the  ordinary  test  not  obtained, 
but  by  stroking  the  anterior  portion  of  the  sole  of  the  foot 
at  the  base  of  the  toes,  typical  Babinski  phenomenon  resulted. 
There  was  practically  complete  loss  of  sense  of  position 
in  toes ;  pain  sense  somewhat  diminished  over  the  feet ;  sense 
of  contact  preserved,  although  answers  to  questions  concern- 
ing sensation  were  sometimes  uncertain;  there  was  marked 
disturbance  of  sense  of  position  in  the  hands;  no  individual 
tremor  of  the  head  except  when  held  in  a  fixed  position; 
no  cranial  nerve  palsies;   difficult  fixation  of  eyes. 

Since  the  foregoing  examination  there  was  a  constant 
gradual  failure  up  to  the  time  of  her  death,  with  an  increase 
in  all  symptoms ;  speech  became  scarcely  intelligible ;  tremor 
remained  very  much  greater  on  the  right  than  on  the  left; 
movements  of  any  sort  were  practically  impossible  on  ac- 
count of  the  violence  of  the  muscular  movement;  there  was  a 
somewhat  definite  tendency  toward  mental  failure,  but  the 
sense  of  well-being  continued ;  there  were  no  complaints  what- 
ever of  pain;  exact  determinations  of  sensory  disturbance 
became  difficult  owing  to  the  mental  state  of  the  patient. 
The  urine  showed  no  significant  abnormality.  Examination 
of  the  eyes  showed  no  central  color  scotoma;  normal  fields 
of  vision  somewhat  reduced;  the  disk  showed  pallor  of  the 
temporal  side;  fundus  otherwise  normal.  She  died  March 
20,  1904,  after  an  illness  of  about  five  years. 


SPINAL   CORD. 


127 


Autopsy.  The  autopsy  revealed  widely  extended  areas 
of  sclerosis  throughout  the  entire  spinal  cord  and  brain. 
Microscopic  examination  of  these  areas  showed  the  char- 
acteristic loss  of  myelin  with  less  completely  destroyed 
axones,  the  whole  central  nervous  system  presenting  a  per- 
fectly typical  picture  of  a 
very  widespread  multiple 
sclerosis. 

Diagnosis.  This  case  at 
first  simulated  a  systemic 
cord  lesion  with  a  spastic 
paraplegia  as  the  predomi- 
nant sign.  Later,  tremor 
or,  better  described,  ataxia 
of  the  intention  type,  nystag- 
mus and  a  characteristic 
scanning  speech  defect  de- 
veloped, rendering  the  diagnosis  of  Multiple  Sclerosis  ab- 
solutely certain.  At  no  time  after  the  very  earliest  stages 
was  the  diagnosis  in  doubt. 

Prognosis.  The  patient  lived  about  five  years,  about  an 
average  period  of  life  in  this  disease,  although  it  undoubtedly 
may  in  some  instances  run  a  much  quicker  course  and  in 
others  be  extended  over  a  much  longer  period  with  long  re- 
missions of  symptoms.  It  has  in  fact  been  maintained  that 
certain  cases  recover,  but  this  must  be  regarded  with  extreme 
doubt. 

Treatment.  In  the  present  state  of  our  knowledge  the  treat- 
ment is  merely  palliative.  There  are  no  methods  at  our  dis- 
posal of  combating  the  progress  of  the  sclerosis. 


Fig.  20.     Case  50. 

Section   through   pons,  showing  areas   of  sclerosis 
(shaded). 


128  CASE   HISTORIES    IN    NEUROLOGY. 

Case  51.  N.,  seventeen  years  old,  was  first  seen  August 
13,  1909.  Her  attention  had  first  been  called  to  her  condition 
on  putting  her  feet  into  a  hot  bath.  She  noticed  nothing 
unusual  in  the  left  leg  but  on  putting  the  right  in  the  water, 
the  heat  was  so  extreme  that  she  was  obliged  to  withdraw 
it  immediately.  Her  attention  having  been  called  to  the 
matter,  she  thereafter  noticed  that  she  could  not  recognize 
dift'erences  in  temperature  over  the  whole  left  leg.  Her  general 
health  had  been  good;  there  was  no  tuberculosis  in  her 
family;  she  had  had  scarlet  fever  when  a  child  and  other 
children's  diseases,  but  nothing  bearing  on  the  present 
situation.  In  1900  adenoids  had  been  removed.  She  was  an 
unusually  well-developed  girl,  with  an  appearance  of  perfect 
health. 

Examination  revealed  no  abnormality  whatever  with  the 
cranial  nerv^es,  arms,  heart  or  other  thoracic  organs.  The  left 
leg  showed  a  complete  anesthesia  to  temperature,  extending 
both  front  and  back  over  the  entire  extremity  and  up  to  about 
the  level  of  the  umbilicus.  The  same  area  was  also  insensi- 
tive to  painful  stimuli.  In  spite  of  this  fact,  contact  of  the 
most  delicate  sort  was  readily  recognized  over  the  entire  area. 
This  dissociation  of  sensation  was  perfectly  definite.  All 
motions  of  the  leg  were  possible,  although  perhaps  slightly 
restricted  in  the  toes  of  the  affected  foot.  There  was  no  mus- 
cular atrophy  and  no  fibrillation.  The  knee  jerks  w^ere  active 
on  both  sides  but  rather  more  so  on  the  right.  There  was  no 
Babinski  sign;  no  clonus;  the  Achilles  reflex  was  somewhat 
more  active  on  the  right  than  on  the  left.  She  had  noticed 
for  some  time  a  tendency  to  lose  the  great  toe  nail  on  the  left 
foot  without  adequate  cause.  This  had  happened  twice 
but  was  not  a  constant  diffi.culty.  There  was  also  an  area 
of  scleroderma  on  the  upper  inner  side  of  the  left  thigh  which 
was  persistent.  There  was  no  curvature  of  the  spine,  no  pain 
on  pressure  over  the  nerves,  the  muscular  development  of 
both  legs  was  excellent  and  equal  on  the  two  sides.  There  was 
no  involvement  whatever  of  the  bladder  or  rectum.  At  times, 
there  was  a  possible  slight  limp,  but  this  was  not  constant. 
Examined  a  year  and  a  half  later,  the  condition  was  prac- 
tically unchanged.     No  atrophy  had  developed;   the  sphinc- 


SPINAL    CORD. 


129 


ters  were  still  unlnvolved;  the  trophic  disturbances  in  the 
toenail  were  somewhat  improved;  the  general  areas  of  dis- 
turbed sensibility  and  the  dissociation  were  as  before.  The 
right  leg  was,  and  has  remained,  entirely  uninvolved. 

Diagnosis.  So  marked  a  dissociation  of  sensation  as  here 
observed  leads  to  the  supposition  that  the  lesion  producing 
it  lies  within  the  substance  of  the  cord  in  its  dorsal  portion 
involving  the  fibers  which  subserve  pain  and  temperature 
(crossed)  and  sparing  those  which  subserve  contact,  for  the 
most  part  uncrossed  and  occupying  the  dorsal  columns  of 
the  cord.  (See  Case  48,  also  Fig.  4.)  The  usual  lesion  causing 
this  disturbance  is  a  gliosis  or  Syringomyelia.  It  is  evident 
that  a  lesion  lying  external  to 
the  cord  would  involve  all 
forms  of  sensibility.  The 
dissociation  in  the  absence 
of  definite  injury  through 
trauma  (Case  48)  is  there- 
fore the  deciding  factor  in 
diagnosis.  In  later  stages, 
as  the  gliosis  spreads,  the 
ventral  horns  are  apt  to  be 
invaded,  leading  to  a  charac- 
teristic   muscular    atrophy. 


00 


Fig. 


TliP>  ncnal  AYacro-p-ra tinn  nf  ^^°^  ^  "^^^^  °^  syringomyelia;  lumbar  region, 
A  1J.C  UC3UC11  c^dggcidLUjii  KJi.  showing  cavity  formation  in  dorsal  columns  and  de- 
,11  n  •„     J 1.        1  generation  of  pyramidal  tracts. 

the  deep  renexes  m  the  legs  ^ 

(not  observed  in  this  case)  is  brought  about  by  pressure  upon 
or  partial  destruction  of  the  pyramidal  tracts  abo\'e. 
.Trophic  disorder,  in  this  case  loss  of  the  toenail,  is  a  com- 
mon accompaniment  of  the  disease.  The  unusual  features 
of  the  case  are  the  sharp  localization  to  one  leg,  the  lack 
of  muscular  atrophy  and  the  apparently  stationary  character 
of  the  process.  The  common  site  of  the  lesion  is  in  the 
cervical  region,  the  cavity  formation  extending  a  varying 
distance  up  and  down  the  cord ;  the  lumbar  region  is  much 
less  frequently  involved.  The  differential  diagnosis  from 
progressive  muscular  atrophy  of  the  spinal  type  lies  in  the 
fact  that  there  is  no  sensory  disorder  in  an  uncompli- 
cated  muscular  atrophy.     The   differential   diagnosis   from 


130  CASE   HISTORIES    IN    NEUROLOGY. 

multiple  neuritis  is  often  difficult  and  must  be  made  from  the 
lack  of  dissociation  of  sensation  in  neuritis,  from  pain  on 
pressure  over  the  ner\'e  trunks  in  the  latter  condition  and 
from  the  general  difference  of  distribution  of  the  two  processes. 
Syringomyelia  usually  manifests  itself  by  atrophy  and  dis- 
sociated sensation  in  the  upper  extremities  with  spasticity 
in  the  lower,  but  without  spontaneous  pain  or  pain  on  pres- 
sure over  nerve  trunks.  This  grouping  of  symptoms  does  not 
occur  in  neuritis.  The  history  given  above  is  not  a  typical 
picture  of  syringomyelia,  but  the  perfectly  defined  loss  of 
perception  of  pain  and  temperature,  with  retained  sense  of 
contact,  permits  of  no  other  diagnosis  in  spite  of  the  lack 
of  other  signs,  which  as  the  disease  progresses  will  no  doubt 
develop. 

Prognosis.  The  location  of  the  process  in  the  lumbar  re- 
gion and  its  evident  extremely  slow  development  render  the 
outlook  for  life  good.  Trophic  conditions  in  the  anesthetic 
parts  are  likely  to  be  a  constant  source  of  annoyance  and 
possible  danger. 

Treatment.  No  means  has  as  yet  been  found  to  check 
the  progress  of  the  gliosis. 


SPINAL   CORD.  131 

Case  52.  E.,  a  man  thirty-three  years  old,  unmarried,  by 
occupation  an  amalgamated  gold  miller,  was  first  admitted 
to  a  hospital  February  12,  1903.  He  was  discharged  and 
readmitted,  January  i,  1904,  for  the  treatment  of  trophic 
ulcers  and  asthma. 

The  family  history  had  no  bearing  on  the  condition. 
The  matter  of  chief  interest  in  the  personal  history  was  the 
presence  of  a  sacral  spina  bifida,  from  which  his  disabilities, 
excepting  his  asthma,  came.  On  several  occasions  he  had  had 
cystitis.  He  had  always  had  incontinence  of  urine  and  wore 
a  urinal  constantly.  His  bowels  moved  irregularly,  and 
coughing  was  apt  to  force  out  a  small  amount  of  feces;  if 
the  desire  for  defecation  was  not  soon  gratified,  he  occasionally 
had  incontinence.  This  had  remained  unchanged  throughout 
his  life.  Five  years  before  entrance  to  the  hospital,  he  was 
treated  for  three  months  for  an  ulcer  on  the  right  side  of  the 
right  foot  at  the  base  of  the  little  toe,  with  necrosis  of  bone. 
The  ulcer  finally  healed.  Four  years  later  a  similar  condition 
appeared  on  the  left  foot,  for  which  he  was  again  treated  with 
final  healing.  He  was  again  admitted  to  the  hospital  with 
a  recurrence  and  necrosis  of  bone.  He  had  always  noticed 
diminution  of  sensation  over  and  above  the  tumor  caused 
by  the  spina  bifida  and  in  the  legs  and  feet.  Except  when 
struck,  the  spinal  defect  had  itself  caused  him  no  trouble. 
On  those  occasions,  however,  when  it  had  accidentally  been 
struck,  he  said  "  he  dropped  like  a  shot  "  and  had  a  tonic 
convulsion  depending  upon  the  severity  of  the  blow.  He  made 
the  statement  that  "  he  was  once  paralyzed  for  three  days  as 
a  result  of  a  hard  blow  received  there,  and  was  in  agony  from 
a  feeling  of  pins  and  needles  over  his  legs."  Except  for  the 
awkwardness  due  to  deformity  of  his  feet,  he  was  perfectly 
able  to  walk,  and  he  maintained  that  his  sexual  capacity 
was  unimpaired.  He  had  had  no  venereal  disease,  had  been 
very  moderate  in  the  use  of  alcohol  and  tobacco  and  had  been 
able  to  learn  and  successfully  apply  a  trade  requiring  physical 
effort  and  manual  dexterity.  In  spite  of  urinary  and  fecal 
incontinence,  his  companions  had  not  recognized  his  disabili- 
ties. 

Physical    examination  gave    the  following  results:     Well- 


132 


CASE   HISTORIES    IN    NEUROLOGY. 


developed  man,  with  no  obvious  signs  of  disability  except  the 
easily  noticeable  deformity  of  the  feet.  Tongue,  chest,  —  ex- 
cept at  times  for  asthmatic  rales,  —  heart,  abdomen  and  ab- 
dominal organs  normal.  Directly  over  the  sacrum  was  a  hard, 
doubtfully  fluctuant,  round  tumor,  2-^-  inches  by  i-^-  inches  in 
diameter,  the  upper  level  being  i-^  inches  below  the  posterior 
superiorspine  of  the  ilium,  and  the  lower  between  two  and  three 
inches  above  the  anus.  Pressure  over  the  tumor  produced  pain. 
Gentle  touch  over  the  tumor  was  not  felt;  pin  prick  very 
slightly  felt  as  touch  (pressure?) ;   outer  side  of  left  foot  cooler 


Fig.  22.     Case  52.     Areas  of  Anesthesia  shaded. 


than  inner;  loss  of  muscle  sense  in  toes;  legs,  in  general, 
cold,  cyanotic  and  more  or  less  discolored;  tremor  of  thigh 
muscles  (excitement?);  knee  jerks  normal,  no  ankle  clonus; 
plantar  present;  no  front  tap;  no  Achilles;  no  cremasteric; 
abdominal  and  epigastric  reflexes,  also,  not  obtained.  The 
feet  both  showed  marked  clubbing,  which  was  apparently 
gradually  increasing,  interfering  considerably  with  walking. 
There  was  slight  Romberg,  due,  he  thought,  to  the  deformity 
of  the  feet.    There  was  a  scar  on  the  under  surface  of  the  right 


SPINAL   CORD.  133 

foot,  at  the  tarso-metatarsal  joint.  On  the  left  foot,  a  sinus 
over  the  fifth  metatarsal  joint  extended  upwards  about  an 
inch  and  a  half;  the  bone  was  necrotic;  moderate  purulent 
discharge;  considerable  swelling  of  the  foot,  expecially  of 
the  dorsum,  with  some  induration.  There  were  also  slight 
excoriations  in  both  gluteal  folds.  Except  for  the  limitation 
of  motion  dependent  necessarily  upon  the  deformity  of  the 
feet,  no  motor  paralysis  was  discoverable.  Flexion  at  the 
ankle  and  movements  of  the  toes  were  possible,  though  natu- 
rally imperfect.  Movements  at  the  knees  and  hip  were  per- 
fectly free  and  made  with  good  strength.  There  was  pro- 
trusion of  the  anus.  The  sensory  loss  was  as  indicated  in  the 
diagrams.  The  areas  deeply  shaded  were  practically  com- 
pletely anesthetic,  but  the  anesthesia  everywhere  faded,  out 
at  the  borders  into  the  normal. 

Treatment  at  the  hospital  resulted  in  a  final  healing  of  the 
foot  ulcer,  in  an  amelioration  of  the  asthmatic  condition, 
and  he  was  discharged.  A  recurrence  of  ulceration  in  both 
feet  led  to  his  return  a  few  months  later.  In  general,  the  con- 
dition remained  unchanged,  excepting,  as  he  thought,  for  an 
increase  of  the  club-foot  deformity;  at  a  recent  examination, 
also,  the  plantar  reflex  was  reported  as  absent,  instead  of 
present  as  before  noted.  The  patient  remained  physically 
well ;  the  ulcers  and  club  feet  combined  interfered  with  walk- 
ing, which  was  otherwise  perfectly  possible,  and  his  scrupu- 
lous care  had  prevented  the  complications  likely  to  result 
,  from  urinary  incontinence.  He  has  not  been  seen  for  several 
years,  and  the  final  outcome  of  his  difficulty  is  not  known. 

Diagnosis.  The  diagnosis  of  this  condition  presents  no 
difficulties,  since  the  deformity  resulting  from  the  imper- 
fect closure  of  the  spinal  canal  is  apparent. 

Prognosis.  The  prognosis  of  spina  bifida  in  general 
depends  upon  the  degree  of  destruction  of  the  cord  and  the 
consequent  amount  of  sensory  disorder.  Bedsores  or  other 
trophic  disturbances  are  extremely  likely  to  occur.  In  this 
case,  the  extraordinary  care  taken  by  the  patient  had  abso- 
lutely obviated  this  danger.  The  slightest  carelessness,  how- 
ever, would  have  led  to  a  rapidly  fatal  outcome.  Cystitis 
is  a  danger  which  again  by  scrupulous  cleanliness  was  avoided. 


134  CASE   HISTORIES    IN    NEUROLOGY. 

Treatment.  Cleanliness  and  care  of  the  skin  is  the  first 
requisite  in  treatment.    Surgical  interference  was  not  possible. 

Note.  The  points  of  practical  importance  which  a  study 
of  this  case  illustrates  are,  —  the  distribution  of  the  areas 
of  anesthesia  from  lesion  of  sacral  ner\^e  roots;  the  retention 
of  sexual  capacity  in  spite  of  extensive  destruction  of  the 
sacral  ner\^e  roots ;  the  absence  of  m.arked  disturbance  of  gait 
in  spite  of  plantar  anesthesia;  the  practical  possibility  of 
physical  cleanliness  with  both  vesical  and  rectal  incontinence. 


SPINAL    CORD.  135 

Case  53.  U.,  a  married  woman  of  twenty-one,  was  first  seen 
December  18,  1909,  complaining  of  weakness  of  the  legs  and 
back  and  incontinence  of  urine.  She  walked  with  the  greatest 
possible  difficulty  and  with  decided  spasticity.  Her  history, 
in  general,  was  that  previous  to  marriage  she  had  given  birth 
to  a  stillborn  child.  After  marriage,  incident  to  the  birth 
of  her  second  child,  five  weeks  before,  she  had  entered  a 
hospital  for  pelvic  disorder.  She  was  in  poor  general  condi- 
tion at  that  time,  and  had  been  suffering  from  chronic  laryn- 
gitis. Examination  showed  a  subinvolution  of  the  uterus 
with  abdominal  tenderness.  This  was  operated  upon  with 
success.  The  urine  was  negative.  When  examined,  December 
18,  she  made  no  complaint  of  pain,  headache  or  vomiting. 
The  pupils  were  normal  and  the  arms  showed  no  involvement. 
The  legs  were  both  weak  and  extremely  spastic,  the  right 
more  so  than  the  left.  The  knee  jerks  were  greatly  ex- 
aggerated and  ankle  clonus  and  Babinski  sign  were  easily 
obtained  on  the  right,  but  neither  could  be  elicited  on  the  left. 
There  was  also  difficulty  with  the  control  of  the  sphincters, 
but  sensation  in  general  was  essentially  unimpaired. 

After  a  stay  of  several  weeks  in  the  hospital,  she  improved 
considerably  and  at  the  time  of  leaving  was  able  to  walk  with 
some  comfort,  although  she  was  still  spastic.  While  in  the 
hospital  a  Wassermann  test  was  positive.  She  was  given  large 
doses  of  iodide  of  potash  and  mercury  by  inunction  with  the 
^result  that  there  was  a  gradual  but  definite  improvement. 
The  urine  showed  some  pus;  examination  of  the  stools 
gave  no  information  of  consequence.  After  leaving  the  hos- 
pital, treatment  was  continued  with  much  constancy.  On 
November  19,  1910,  examination  showed  considerable  stiff- 
ness of  the  legs,  active  knee  jerks,  the  right  slightly  greater 
than  the  left,  a  more  active  Achilles  on  the  right,  with  clonus 
and  Babinski  as  before.  Sensibility,  as  tested  by  contact, 
prick  and  temperature,  was  unimpaired,  except  for  a  patch 
on  the  outer  side  of  the  right  thigh,  where  all  forms  of  sensi- 
bility were  lost  or  diminished,  with  a  subjective  feeling  of 
heat  in  that  area.  In  general  the  patient  had  greatly  im- 
proved, was  able  to  do  her  housework  but  continued  to  have, 
when  last  seen,  exacerbations  of  symptoms  from  time  to  time. 


136  CASE   HISTORIES   IN    NEUROLOGY. 

Diagnosis.  The  diagnosis  in  this  case  is  undoubtedly  a 
SyphiHtic  Meningo-myeHtis  of  the  dorso-lumbar  cord,  de- 
scribed by  Erb  as  Syphilitic  Spinal  Paralysis.  This  lesion 
is  characterized  by  a  localization  of  the  syphilitic  process 
at  the  lower  portion  of  the  cord,  beginning  in  the  meninges 
and  invading  the  cord  to  a  greater  or  less  degree.  The  process 
occurs  with  sufficient  frequency  to  justify  a  special  designa- 
tion, although  it  is  evident  that  it  is  merely  one  of  the  many 
possible  manifestations  of  syphilis  of  the  central  nervous 
system.  The  diagnosis  is  made  by  the  etiology,  and  a  type 
of  cord  invasion  characterized  by  marked  and  early  spasticity 
(invasion  of  the  pyramidal  tracts)  with  less  conspicuous  dis- 
turbance of  sensation  and  of  sphincter  control. 

Prognosis.  The  prognosis  Is  good,  provided  the  affection 
be  recognized  In  Its  earlier  stages  and  vigorously  treated. 
In  this  case,  it  Is  clear  that  the  cord  has  been  so  far  damaged 
that  its  complete  restoration  Is  impossible.  Improvement 
has  taken  place,  but  not  cure. 

Treatment.  The  treatment  Is  by  vigorous  and  persistent 
use  of  iodide  of  potash  In  dosage  up  to  150  grains  a  day, 
and  mercury,  best  given  by  Inunction  or  by  subcutaneous 
injection.  In  this  case  Iodide  and  mercury  by  inunction 
have  been  administered  over  a  period  of  more  than  a  year 
with  satisfactory  but  not  brilliant  results.  The  process  may, 
however,  be  held  In  check  If  not  completely  relieved.  To  this 
end,  anti-syphilitic  treatment  should  be  Indefinitely  contin- 
ued with  certain  remissions.  Salvarsan  is  of  doubtful  utility 
in  these  cases,  so  far  as  our  present  knowledge  goes. 


SPINAL   CORD.  137 

Case  54.  R.,  forty-five  years  old,  was  admitted  to  a  hospi- 
tal, April  16,  1895.  He  had  had  typhoid  fever  the  preceding 
summer,  and  shortly  after  recovery  noticed  a  lump  about  the 
middle  of  his  back,  which  was  not  painful.  He  soon  experienced 
some  difficulty  in  walking;  under  orthopedic  treatment  the 
lump  decreased  considerably  in  size.  The  patient  denied 
venereal  infection,  and  in  general  had  been  well  antecedent 
to  the  attack  of  typhoid  fever  mentioned.  When  again 
admitted  to  the  hospital  he  was  unable  to  walk  and  com- 
plained of  numbness  of  the  legs  from  the  knees  down.  He 
also  had  some  difficulty  in  micturition,  but  no  incontinence. 
There  was  at  no  time  any  cerebral  disturbance. 

Physical  examination  at  this  time  showed  the  arms  un- 
involved;  passive  movement  in  both  hips  slightly  hindered; 
stiffness  and  rigidity  of  both  legs,  particularly  of  the  right; 
ankles  rigid;  active  movement  impaired  in  all  directions; 
no  ataxia;  feet  in  position  of  marked  plantar  flexion;  knee 
jerks  on  both  sides  very  much  increased,  with  patellar  clonus; 
ankle  clonus  strongly  indicated  on  both  sides;  Babinski 
on  both  sides;  cremaster  present,  slight;  abdominal  and  epi- 
gastric reflexes  normal.  Sensibility  to  pin  prick  was  at  this 
time  unimpaired;  contact  was  also  normal  and  there  was 
no  loss  of  sense  of  position  in  the  toes. 

From  that  time  on  the  symptoms  already  noted  increased 
steadily  in  spite  of  such  treatment  as  was  applied,  the  kypho- 
*  sis  varying  in  size,  dependent  largely  upon  whether  the  patient 
attempted  to  sit  up,  when  it  at  once  increased.  The  spastic 
rigidity  of  the  legs  increased  to  practically  complete  paraple- 
gia with  highly  exaggerated  reflexes,  but  without  marked 
objective  disorder  of  sensibility.  Subjective  sensations 
of  numbness  were,  however,  well  marked;  difficulty  in  mic- 
turition persisted,  and  he  had  at  times  painful  sensations  in 
the  epigastrium  when  he  attempted  to  sit  up.  Contractures 
of  the  feet  became  very  marked,  and  slight  but  definite 
disorders  of  sensation  finally  came  on  in  the  legs ;  the  prick  of 
a  pin  could  no  longer  be  recognized  as  such.  This  condition 
remained  fairly  constant,  but  on  the  whole  there  was  a  steady 
increase  in  the  signs  of  injury  to  the  cord.  Even  under  these 
discouraging    conditions    decided    temporary    improvement 


138 


CASE   HISTORIES    IN    NEUROLOGY.' 


took  place  through  manipulations  of  the  legs  and  through 
wearing  a  leather  jacket.  The  back  became  straight,  some- 
what rigid,  without  kyphosis,  and  he  was  able  to  walk  with 
crutches,  swinging  the  legs  from  the  hips.  From  this  time  on 
until  his  death  in  February,  1902,  he  remained  essentially 
the  same,  death  finally  resulting  from  extension  of  the  tuber- 
culous process  and  amyloid  degeneration. 

Examination  of  the  spine  showed  a  complete  tuberculous 
disintegration  of  the  body  of  the  eleventh  thoracic  vertebra 


Fig.  23.     Case  54. 
Levels  of  the  cord  showing  degeneration. 


with  a  constriction  and  partial  destruction  of  the  cord  at  that 
level,  brought  about  in  great  measure  by  the  effects  of  extra- 
dural pressure.  The  appearance  of  the  cord  is  shown  in  the 
accompanying  figure. 

Diagnosis.  Tuberculosis  of  the  spine  is  much  less  frequent 
in  the  adult  than  in  the  child.  The  appearance  of  a  kyphos, 
however,  with  accompanying  signs  of  cord  involvement, 
should  always  lead  to  the  suspicion  of  a  tuberculous  process. 
Carcinoma  of  the  vertebrae  may  at  times  closely  simulate 


SPINAL   CORD  139 

Pott's  disease,  but  is  usually  accompanied  with  more  pain. 
Search  also  is  likely  to  reveal  the  primary  tumor  in  breast, 
stomach  or  uterus. 

Prognosis.  Pott's  disease  is  not  in  itself  a  fatal  disease, 
and  if  properly  treated  early  in  its  development  should  lead 
to  no  marked  deformity  or  involvement  of  the  cord.  In  this 
case  treatment  was  not  begun  soon  enough ,  and  in  any  event 
the  dissemination  of  the  tuberculous  process  to  other  organs 
could  not  have  been  prevented. 

Treatment.  The  treatment  is  sufficiently  indicated  in  the 
foregoing  history. 


140  CASE   HISTORIES   IN    NEUROLOGY. 

Case  55.  O.,  a  married  woman  of  sixty- three,  was  seen 
August  28,  1902.  The  history  she  gave  was  that  apart  from 
rheumatism  and  two  miscarriages  she  had  been,  in  general,  well, 
but  that  in  April,  1902,  she  had  had  pain  in  her  back  at  about 
the  level  of  the  lower  rib  border.  She  was  obliged  to  take  to 
her  bed  in  June  with  increasing  weakness  of  the  legs,  so  that 
finally  she  was  unable  to  stand  without  support.  The  legs 
also  felt  numb  and  there  were  "  prickly  "  sensations.  There 
had  been  no  difficulty  with  micturition.  A  few  days  before 
being  seen,  she  had  somewhat  suddenly  lost  practically  all 
power  in  the  legs,  and  the  pain  about  her  body,  sharply  local- 
ized at  about  the  level  of  the  umbilicus,  had  increased  in 
intensity.  Further  examination  showed  a  scirrhus  cancer  of 
the  right  breast  in  its  upper  outer  quadrant  with  retraction 
of  the  nipple  and  extreme  involvement  of  the  axillary  glands. 
Difficulty  in  urination  also  developed  with  the  general  increase 
of  the  cord  symptoms. 

Physical  examination  showed  a  general,  marked  blunting 
of  sensation  to  pain  and  contact  in  the  legs,  extending  up 
to  about  the  level  of  the  umbilicus.  Associated  with  this 
was  marked  weakness  of  the  legs.  The  knee  jerks  were  ex- 
tremely active;  there  was  double  ankle  clonus,  but  question- 
able Babinski.  The  pupils  were  normal,  the  heart  showed 
no  abnormality  and  mentally  the  patient  was  clear.  The 
hemoglobin  was  100%.  She  died  about  a  month  after  being 
seen,  after  having  lost  all  use  of  her  legs.  For  ten  days  before 
her  death,  she  was  in  semi-comatose  condition. 

Diagnosis.  It  is  evident  that  this  patient  had  a  metastatic 
carcinomatous  infiltration  of  the  spinal  cord  at  the  level  of 
about  the  tenth  thoracic  vertebra,  consequent  and  directly 
derived  from  a  pre-existent  carcinoma  of  the  breast.  In 
this  case,  the  cord  suffered  a  practically  transverse  lesion, 
characterized  by  disturbances  of  motion,  sensation  and  sphinc- 
ter control  below  the  point  of  the  lesion.  It  is  of  interest 
that  the  lesion  of  the  cord  lay  considerably  below  the  original 
focus.  It  is  more  usual  that  secondary  involvements  of  the 
cord  from  breast  cancer  affect  the  cervical  or  upper  thoracic 
region,  whereas  metastases  from  the  uterus  are  likely  to  in- 
volve th^  lower  cord,  and  from  the  stomach  the  mid-thoracic 


SPINAL   CORD.  141 

region.  Cord  symptoms  developing  in  the  presence  of  car- 
cinoma elsewhere  should  always  give  rise  to  a  suspicion  of 
metastases;  and  conversely  signs  of  cord  tumor,  particularly 
in  elderly  persons,  should  lead  to  a  suspicion  and  a  consequent 
investigation  as  to  the  existence  of  tumor  in  other  parts  of 
the  body. 

Prognosis.  Carcinoma  involving  the  vertebrae  and  cord 
is  almost  invariably  metastatic,  and  is  in  all  cases  a  fatal 
disease. 

Treatment.  Operative  treatment  in  this  case  was  consid- 
ered, but  not  carried  out  in  view  of  the  wide  invasion  of  the 
cancer  in  other  tissues,  as  well  as  in  the  cord.  The  use  of  mor- 
phine to  relieve  the  pain  in  these  cases,  which  is  often  ex- 
cruciating in  character,  is  wholly  justified,  both  by  the 
immediate  suffering  and  the  inevitably  fatal  outcome. 


142  CASE   HISTORIES    IN    NEUROLOGY. 

Case  56.  L.,  an  unmarried  woman  of  twenty-seven,  was 
first  seen  early  in  October,  1904.  She  had  had  malaria  five  or 
six  years  previously,  following  which  what  were  supposed  to  be 
glands  appeared  in  the  neck,  which  have  persisted.  These 
were  somewhat  tender  on  pressure.  For  four  or  five  years 
she  had  not,  in  general,  been  well,  and  there  was  complaint 
of  fatigue  on  exertion.  Two  years  previously,  she  had  noticed 
sweating  of  the  right  side  of  the  face  and  falling  of  the  right 
eyelid.  She  thought  at  that  time  that  her  vision  was  impaired ; 
there  was  no  diplopia.  In  January,  1904,  a  feeling  of  stiffness 
developed  in  the  right  leg  and  she  also  had  "  rheumatism  " 
of  the  left  knee  and  foot.  There  was  no  sharp  pain,  and  what 
headaches  she  had  she  thought  depended  on  the  use  of  her 
eyes.  For  six  or  eight  months  there  had  been  numbness  of 
the  right  foot,  less  of  the  leg.  There  had  likewise  been,  while 
confined  to  her  bed,  some  urinary  disorder,  probably  incon- 
tinence. 

Physical  examination  in  October  showed  markedly  unequal 
pupils,  the  left  being  about  three  times  as  large  as  the  right; 
both  reacted  to  light;  the  accommodation  was  normal  and 
there  was  no  hemianopsia.  There  was  no  paralysis  of  the 
ocular  nerves  or  of  the  other  cranial  nerves.  The  hands  were 
free  from  ataxia  and  normal  in  strength,  and  sensation  was, 
in  general,  unimpaired.  Both  knee  jerks  were  markedly 
exaggerated,  the  right  more  than  the  left.  There  was  a  strong 
tendency  to  ankle  clonus  on  the  right  with  a  Babinski  reflex. 
There  was  neither  plantar  nor  Babinski  on  the  left.  Achilles 
was  present  on  both  sides.  The  right  foot  and  leg  were  much 
cooler  than  the  left,  with  some  probable  loss  of  sense  of  posi- 
tion of  the  toes,  especially  on  the  right.  There  were  several 
hard  swellings  of  the  size  of  large  glands  in  the  neck  and  above 
the  axillae,  some  of  which  were  sensitive  on  pressure.  There 
was  a  similar  tumor  in  the  left  groin;  no  glands  were  felt 
at  the  elbows.  These  swellings  she  thought  had  remained 
about  the  same  for  a  period  of  five  or  six  years. 

Administration  of  iodide  of  potash  accomplished  nothing, 
nor  did  massage  help  the  situation.  She  continually  grew 
worse,  fell  more  easily  than  before,  was  restless  at  night; 
some  rectal  incontinence  developed,  together  with  the  urinary 


SPINAL   CORD.  143 

difficulty;  she  had  sensations  of  throbbing  and  burning  in 
the  right  leg,  together  with  some  sharp  pain  down  the  leg  and 
in  the  back  and  left  side.  By  December,  walking  had  be- 
come practically  impossible,  there  was  marked  spasmodic 
contraction  of  the  legs,  especially  on  the  right,  and  flexion 
at  the  knee  and  hip  with  abduction  at  the  thigh.  Sensation 
in  the  feet  became  blunted.  Ataxia  of  the  arms  did  not  de- 
velop. The  blood  showed  hemoglobin  between  80  and  90%. 
More  pain  developed  in  the  right  arm  and  both  legs,  with 
persistent  contractures.  She  was  evidently  rapidly  growing 
worse. 

The  patient,  eight  months  later,  passed  into  the  hands  of 
a  colleague  who  diagnosticated  multiple  tumors,  one  or  more 
of  which  were  invading  the  cord.  During  the  interval,  she 
had  completely  lost  the  power  of  walking  and  all  control 
of  the  sphincters.  The  sensory  disorders  of  the  legs  had  in- 
creased and  atrophy,  particularly  of  the  right  hand,  had  devel- 
oped. Sweating  and  flushing  had  extended  over  one  entire 
side  of  the  body  and  anesthesia  had  developed  to  a  point 
about  midway  between  the  umbilicus  and  the  breasts,  together 
with  disturbance  in  the  ulnar  distribution  on  both  sides. 
'■At  that  time,  the  patient  stated  that  she  had  been  free  from 
pain  from  the  beginning  of  the  trouble.  A  portion  of  the  tumor 
removed  from  the  right  thigh  showed  it  to  be  a  fibrosarcoma. 
Two  operations  were  done  in  which  the  cord  was  exposed 
at  the  level  of  the  fifth,  sixth,  seventh  cervical  and  first 
thoracic  vertebrae.  An  extradural  tumor  was  found  adherent 
to  the  fifth  cervical  vertebra  about  the  size  of  an  olive  stone, 
which  had  flattened  and  compressed  the  cord,  particularly 
on  the  right  side  and  ventrally.  Improvement  began  at  once 
after  the  operation  with  a  return  of  sensation  in  the  legs, 
increased  power  of  motion  and  recovery  of  control  of  the 
sphincters.  The  spasticity  also  improved  and  walking  began 
to  be  possible.  The  eye  condition  became  more  normal. 
Her  later  improvement  was  very  marked,  but  at  the  last 
report  recovery  had  not  entirely  taken  place. 

Diagnosis.  The  original  diagnosis  in  this  case  was  incorrect. 
The  spastic  condition  of  the  legs,  together  with  sphincter 
disorder  and  some  disturbance  of  sensation,  in  the  absence  of 


144  CASE   HISTORIES    IN    NEUROLOGY. 

any  definite  complaint  of  pain  led  to  the  supposition  that  the 
patient  was  suffering  from  a  diffuse  combined  degeneration 
of  the  cord  giving  rise  to  an  ataxic  paraplegia.  More  impor- 
tance should  have  been  attached  to  the  inequality  of  the  deep 
reflexes  on  the  two  sides  and  especially  to  the  narrowing  of 
one  palpebral  fissure,  inequality  of  the  pupils  and  unilateral 
sweating,  as  indicative  of  a  focal  lesion.  The  presence  of 
other  tumors,  mistaken  for  glands,  should  also  have  excited 
suspicion  when  the  patient  was  first  seen.  An  operation  at 
that  time  would  undoubtedly  have  resulted,  so  far  as  the 
spinal  symptoms  were  concerned,  in  a  practically  complete 
cure.  Too  much  stress  was  laid  upon  the  absence  of  sharp, 
localizing  pain.  In  the  light  of  the  subsequent  history,  and 
particularly  when  reviewed  after  the  demonstration  of  the 
existence  of  a  tumor  by  operation,  it  appears  that  the  early 
diagnosis  of  diffuse  lesion  of  the  cord  was  entirely  unwarranted. 
In  partial  justification  of  the  early  opinion,  it  may  be  said 
that  the  symptoms  developed  rapidly  immediately  before  the 
operation  and  that  the  beginning  involvement  of  the  arms 
was  particularly  suggestive.  The  lesson  of  the  case  is, 
that  even  in  the  absence  of  localized  pain  in  the  distribution 
of  the  spinal  segment  involved,  a  diagnosis  of  tumor  of  the 
cord  may  still  be  made  if  the  symptoms  are  somewhat  uni- 
lateral in  character  and  other  signs  point  toward  a  focal  lesion. 
A  more  careful  examination  of  sensation  in  relation  to  the 
motor  disability  would  have  been  desirable  to  determine 
definitely  whether  the  significant  Brown-Sequard  complex 
existed  at  any  period  of  the  disease. 

Prognosis.  So  far  as  known,  the  outcome  of  this  case  has 
been  favorable.  The  danger  lies  not  so  much  in  further  in- 
volvement of  the  central  nervous  system  as  in  the  growth 
and  extension  of  the  more  peripheral  tumors.  It  is  unfor- 
tunate that  the  operation  was  not  done  earlier  in  the  course 
of  the  disease;  in  that  event,  no  doubt  the  spasticity  which 
persisted  to  some  degree  would  have  been  entirely  obviated. 

Treatment.  Early  operation  is  desirable  in  Cord  Tumors 
before  any  considerable  degree  of  pressure  has  been  exerted 
upon  the  cord.  Many  of  these  tumors  lie  under  the  dura, 
as  in  this  case,  in  such  a  position  as  to  be  easily  removed. 


SPINAL   CORD.  145 

Hence,  their  treatment  by  surgical  means  offers  a  very  hope- 
ful field.  Drugs  are  unavailing  except  in  cases  of  syphilitic 
lesion,  when  a  vigorous  use  of  iodide  of  potash  and  mercury 
often  brings  about  very  great  Improvement.  The  removal 
of  laminae  leads  to  no  permanent  discomfort  or  weakness  of 
the  spinal  column,  and  in  skilled  hands  is  an  operation  of  no 
great  difficulty. 


146  CASE  HISTORIES  IN  NEUROLOGY. 

Case  57.  O.,  a  woman  twenty-four  years  old,  married, 
noticed  the  first  symptom  of  the  disease  from  which  she 
later  died,  September  25,  1905.  She  was  at  the  time  pregnant, 
but  had  not  hitherto  suffered  more  than  the  usual  discomfort. 
On  September  25,  during  the  night,  while  traveling  in  a  sleep- 
ing car,  she  was  suddenly  seized  with  pain  radiating  down 
both  legs.  The  next  day  the  pain  and  discomfort  continued 
and  on  the  whole  increased  in  severity.  During  the  following 
month,  October,  she  had  constant  and  excruciating  pain. 
During  this  time  she  was  unable  to  lie  in  bed,  and  slept  propped 
with  pillows,  in  a  semi-erect  position.  Treatment  by  violet 
rays  did  not  result  in  benefit.  In  spite  of  her  discomfort 
she  slept  from  four  to  five  hours  during  the  night,  although 
often  waked  by  pain.  Her  mind  was  perfectly  clear.  The 
first  week  in  November  there  was  apparent  improvement, 
although  she  was  never  wholly  free  from  pain.  At  this  time, 
the  condition  was  diagnosticated  as  neuritis.  She  was  then 
suffering  from  extremely  severe  pain  in  the  legs,  coming  on 
in  attacks  which  lasted  several  hours.  There  was  also  com- 
plaint of  pain  in  the  back.  Relaxation  of  the  sacro-iliac  liga- 
ments w^as  shown  not  to  be  the  cause  of  her  discomfort. 
On  December  7,  there  was  complaint  of  pain  and  stiffness 
of  the  legs,  pain  in  the  region  of  the  bladder,  and  pressure  in 
the  rectum.  The  patient  was  extremely  restless  and  much 
constipated,  but  obtained  a  fair  amount  of  sleep.  During 
the  days  immediately  following  there  was  much  pain  in  the 
legs  and  back  and  a  constant  desire  to  sit  up  on  account  of 
the  greater  comfort  while  in  that  position.  At  times  the  pain 
in  the  back  and  legs  would  recur  immediately  on  lying  down. 
The  urine  was  passed  freely,  but  was  under  control.  The 
restlessness,  evidently  induced  by  pain,  was  constant  and 
distressing,  necessitating  very  frequent  changes  of  position, 
both  in  bed  and  out.  At  times  the  pain  seemed  to  become 
unbearable,  but  frequently  was  alleviated  by  drugs  other  than 
morphine.  Toward  the  middle  of  December,  there  was 
complaint  of  soreness  in  hips,  legs  and  knees.  She  found 
relief  in  walking;  micturition  was  frequent,  but  in  spite  of 
this  fact  she  complained  that  the  bladder  "  felt  bursting." 
On  December  22,  there  was  for  the  first  time  some  difficulty 


SPINAL   CORD.  147 

in  passing  urine,  with  continuance  of  the  complaint  of  pain  in 
the  bladder,  at  times  described  as  "intense."  Catheterization 
relieved  this  symptom  for  the  time  being  and  large  amounts 
of  urine  were  passed  when  the  catheter  was  not  used,  but  only 
after  efforts  lasting  an  hour  or  more.  At  about  this  time  she 
became  irrational  at  night.  Excessive  pain  in  the  back  and 
legs  continued,  and  the  legs  and  feet  began  to  grow  weak. 
On  December  24,  when  out  of  bed,  she  was  practically  helpless, 
and  could  not  support  herself  properly  when  standing. 
She  was,  however,  still  able  to  pass  urine,  although  with  much 
difficulty.  On  December  25,  control  of  the  feet  and  legs  was 
practically  lost,  and  there  was  complaint  of  numbness  of  the 
legs.  In  addition  she  had  had  hallucinations  both  of  sight  and 
hearing  and  occasional  disorientation  both  as  to  time  and 
place.  She  was  not  depressed,  and  questions  were  answered 
with  absolute,  clearness. 

Examination  of  the  legs  objectively  showed  that  pain  and 
contact  were  felt  and  correctly  interpreted,  although  blunted 
over  certain  areas  below  the  knee.  Temperature  was  cor- 
rectly recognized  over  both  legs  wherever  tested.  The  rrius- 
cular  sensibility  of  the  toes  was  unimpaired,  but  the  soles 
were  not  ticklish.  The  motion  of  the  toes  and  ankles  was 
preserved  and  carried  out  with  a  fair  degree  of  strength. 
Both  flexion  and  extension  of  the  knees,  were,  however,  very 
much  affected,  and,  in  fact,  very  little  movement  was  possible. 
The  knee  jerks  were  absent  in  spite  of  reenforcement.  There 
was  no  plantar  reflex,  however;  no  clonus,  and  no  Achilles 
reflex.  The  paralysis  was  flaccid.  Headache,  of  which  com- 
plaint was  made,  was  somewhat  vague  in  character  and  at 
this  time  wholly  subordinate  to  the  more  intense  pain  of 
the  lower  back  and  legs.  Mentally,  she  remained  much  dis- 
turbed, and  the  condition  of  the  legs  also  grew  progressively 
worse.  Sensibility  was  more  impaired  and  the  disturbance 
extended  upward,  involving  the  thighs.  Urinary  incontinence 
became  complete,  and  there  was  absolute  loss  of  power  in  the 
legs  and  thighs  on  January  11.  Except  for  slight  retained 
sensation  in  the  upper  part  of  the  thighs,  the  loss  was  com- 
plete. Slightly  higher  in  the  gluteal  region  and  to  a 
point    about    midway    between    the    pubes    and    umbilicus, 


148 


CASE   HISTORIES    IN    NEUROLOGY. 


there  was  marked  hyperesthesia.  Examination  of  the  urine 
at  this  time  was  as  follows:  Twenty-four  hour  amount, 
2,900ccm.;  sp.gr.,  1,004;  color,  pale;  reaction,  acid,  uph., — ; 
ind., —  ;  sulph., —  ;  acetone,  o;  urea,  23.999  grn-;  uric 
acid,  0.17;  chlor.,  4.4;  phos.  a.,  0.14;  sugar,  o;  albumin, 
slightest  possible  trace;  uric  acid  to  urea,  i  to  141.  Sedi- 
ment, occasional  hyaline  and  granular  casts  with  occasional 

squamous  cells  and  leucocytes. 
Lead  and  arsenic  both  absent. 
Later,  stiffness  of  the  neck 
associated  with  extreme  sen- 
sitiveness on  moving  the  head 
in  any  direction  was  added  to 
her  series  of  symptoms.  The 
headache  became  severe,  and 
on  January  11  a  somewhat 
doubtful  choked  disk  made  it- 
self evident.  This  rapidly  in- 
creased to  a  high  degree  of 
swelling,  with  rapid  diminu- 
tion of  vision  up  to  complete 
blindness.  Paralysis  of  sensa- 
tion and  motion  of  the  legs 
and  sphincters  remained  com- 
plete. On  January  13,  a  girl 
baby  was  bom,  low  forceps 
alone  being  necessary  after  an 
Fig.  24.  Case  57.  absolutcly  palnlcss  labor.  Con- 

Areas  of  anesthesia  and  hyperesthesia,  January    valeSCCnCC  from  child-birth  WaS 
II,  1906.     A,  Hyperesthetic  zone.     B,  Anesthesia 

almost  complete.     C,  Complete  anesthesia.     Dis-    normal    and     UnCVCntful.         Hcr 
orders  of  sensation  occurring   later  in   body  and 
upper  extremities  not  charted.  mCntal   COnfusioU,  hoWCVCr,    iu- 

creased ;  she  made  various  complaints  of  pain  in  the  back  and 
unusual  sensations  in  her  arms.  A  careful  objective  examina- 
tion was  impossible  on  account  of  her  disordered  mind .  Her  in- 
terest in  the  baby  was  transient.  She  became  incoherent,  ap- 
prehensive at  times,  and  toward  the  end  of  her  life  increasingly 
apathetic.  A  blood  examination  showed  the  following  con- 
ditions. Hemoglobin,  80%;  reds,  6,232,000;  whites,  10,500. 
Stained  specimen  showed  no  achromia  or  other  abnormality. 


SPINAL   CORD. 


149 


No  blasts  or  plasmodia  seen.  Differential  count  of  500  whites 
showed:  Polynuclear,  70.8%;  lymphocytes,  26.6%;  eosino- 
philes,  2.6%.  Toward  the  very  end 
of  her  life  a  slight  paresis  of  the  left 
facial  nerve  was  observed,  also  slight 
disturbance  in  movements  of  the  left 
eye.  She  became  increasingly  stu- 
porous, with,  however,  evidence  of 
pain  from  time  to  time  in  the  back 
and  head.    She  died  March  25. 

Autopsy.  The  autopsy  showed  a 
tumor  of  the  spinal  cord  of  a  small 
round  cell,  sarcomatous  type,  origi- 
nating in  the  cauda  equina  and  sacral 
cord,  destroying  completely  the  lum- 
bar cord  and  invading  especially  the 
dorsal  aspect  of  the  cord  into  the 
cervical  region.  The  brain  showed 
no  other  abnormality  than  an  ex- 
''treme  hydrocephalus,  evidently  due 
to  the  blocking  up  of  the  subdural 
space  of  the  cord  by  the  tumor, 
thereby  preventing  the  outflow  of 
cerebrospinal  fluid. 

Diagnosis.  A  definite  diagnosis 
was  not  made  during  life.  A  lumbar 
puncture  would  undoubtedly  have 
given  a  dry  tap  and  the  study  of 
possible  cells  found  in  the  trochar 
might  have  determined  the  existence 
of  a  tumor.  This  examination  should 
have  been  made.  The  relatively  early 
destruction  of  the  cord  in  the  lumbar 
region  led  to  the  supposition  of  a 
transverse  myelitis  and  confused 
somewhat  the  picture  of  Tumor. 
More  stress  should  have  been  laid 
on  the  bilateral  character  of  the  pain, 
which  Is  extremely  characteristic  of 


Fig.  25. 


8 

Case  A. 


Cross  sections  of  cord  from  lumbar 
to  upper  cervical  region,  showing 
extent  and  position  of  tumor.  8,  Lum- 
bar region,  practically  complete  de- 
struction. In  upper  sections  note 
dorsal  sub-pial  position  of  the  growth. 
The  secondary  degenerations,  mainly 
of  the  dorsal  tracts,  are  explained  by 
the  partial  destruction  of  the  dorsal 
nerve  roots,  portions  of  the  dorsal 
tracts,  and  to  a  much  less  degree  of 
the  dorsal  gray  leading  to  slight  de- 
generation in  Gower's  and  direct 
cerebellar  tracts.  (Accurate  tracings, 
Edinger  drawing  apparatus.) 


150  CASE   HISTORIES    IN    NEUROLOGY. 

cord  tumor.  The  further  complication  of  definite  cerebral 
symptoms  of  a  mental  sort  together  with  manifest  signs  of 
intracranial  pressure  were  not  explained  during  life  and  again 
diverted  attention  from  a  lesion  localized  solely  in  the  cord. 
In  the  light  of  the  autopsy,  much  more  stress  should  have 
been  laid  upon  the  pain,  and  particularly  upon  its  bilateral 
character.  The  supposition  should  also  have  been  entertained 
that  a  very  probable  cause  of  such  a  destructive  lesion  of 
the  cord  in  a  person  of  her  age  would  be  a  rapidly  growing 
tumor.  The  complication  of  pregnancy  rendered  the  diag- 
nosis still  more  difficult. 

Prognosis.  The  disease  was  fatal  in  six  months  from  the 
first  symptoms. 

Treatment.  Had  the  diagnosis  been  early  established  with 
probable  certainty,  operative  interference  would  have  been 
justified.  It  is  possible  that  an  exposure  of  the  cauda  equina 
at  a  very  early  stage  might  have  shown  conditions  which 
could  have  been  relieved.  This  is,  however,  extremely  doubt- 
ful in  view  of  the  extremely  rapid  growth  of  the  tumor  and 
of  its  manifestly  malignant  character.  Without  operation, 
palliative  treatment  was  alone  possible.  Morphine  should 
have  been  much  more  liberally  used  than  it  was  to  alleviate 
what  must  have  been  most  excruciating  pain  owing  to  the 
invasion  practically  thoughout  the  cord  of  the  dorsal  nerve 
roots.  Comparatively  small  relief  was  obtained  from  phe- 
nacetin  and  similar  drugs  of  the  coal-tar  series. 


SPINAL   CORD.  151 

Case  58.  G.,  a  boy  of  fourteen,  had  been  well  until  he  was 
eight  years  old.  He  then  began  to  develop  an  unsteadiness 
of  gait,  insidious  in  onset,  which  was  definitely  established  at 
ten.  He  had  reached  the  high -school  grade  and  had  shown 
no  mental  deficiency.  His  mother  had  been  married  seven- 
teen years  and  gave  the  following  history  of  childbearing. 
The  first  pregnancy  resulted  in  miscarriage  at  the  second 
month;  the  second,  a  boy  born  at  full  term,  was  well;  the 
third  (the  patient)  was  born  eleven  months  after  the  pre- 
ceding child;  following  his  birth  there  were  two  or  three 
miscarriages  at  about  the  second  month.  A  boy  was  then  born, 
later  similarly  affected  as  the  patient  (see  later  statement). 
Thereafter  there  were  a  number  of  miscarriages  at  about  the 
second  month.  The  mother  and  father  had  been  well  so  far 
as  known  and  no  history  of  the  affection  from  which  the  chil- 
dren suffered  was  obtained  in  other  members  of  the  family. 

Examination  of  G.  showed  normal  pupillary  reactions 
with  retained  accommodation;  no  nystagmus;  normal 
vision.  The  other  cranial  nerves  showed  no  abnormality, 
either  of  motion  or  sensation.  The  boy  was  emaciated  but 
without  true  muscular  atrophy;  sensation  of  the  body  and 
arms  was  unimpaired.  There  was,  however,  in  spite  of  ade- 
quate strength  in  the  hands,  marked  ataxia  of  both  arms, 
equal  on  the  two  sides,  with  slight  static  ataxia  also  of  the 
hands.  The  wrist  and  elbow  jerks  were  absent  on  both  sides. 
The  abdominal  and  epigastric  reflexes  were  more  active  on 
the  right  than  on  the  left.  The  cremaster  was  equal  on  the 
two  sides.  There  was  no  difificulty  with  the  sphincters. 
The  gross  strength  of  the  legs  was  excellent.  The  knee  jerks 
were  not  obtained  nor  was  there  ankle  clonus,  Achilles, 
Babinski  or  normal  plantar  reflex.  There  was  no  deformity 
of  the  feet  beyond  slight  hyperextension  of  the  right  great 
toe.  An  attempt  to  place  the  heel  of  one  foot  on  the  knee 
of  the  other  side  resulted  in  extreme  ataxia,  even  with  the 
eyes  open,  and  was  definitely  increased  with  the  eyes  closed. 
In  the  attempt  to  rise  from  a  lying  to  a  sitting  position, 
a  general  incoordination  of  movement  was  excited,  including 
the  head.  There  was  marked  unsteadiness  on  standing  (Rom- 
berg) ;  the  gait  on  attempting  to  walk  was  exceedingly  ataxic. 


152  CASE   HISTORIES    IN    NEUROLOGY. 

For  some  months  his  speech  had  been  slow  and  hesitating. 
The  heart  area  was  normal;  there  were  no  murmurs;  the 
liver  and  spleen  were  not  enlarged;  the  abdomen  was  tym- 
panitic but  showed  no  definite  abnormality. 

G.'s  brother  W.,  eleven  years  old,  had  had  pneumonia  at 
two  and  had  never  been  well  since.  He  also  was  gradually 
growing  worse  with  very  similar  symptoms  to  those  of  his 
older  brother.      He  had   slight  nystagmus;    marked   ataxia 

of  both  upper  extremities;  absent 
reflexes  in  the  arms;  a  systolic  mur- 
mur at  the  heart  apex.  He  was 
backward  at  school  and  had  more 
or  less  incontinence,  undoubtedly 
due  to  his  defective  mental  develop- 
FiG.  26.  ment.      His  condition  was  in  general 

shS'd^renta'iiL^^tthl^^^^         similar  to  that  of  his  brother,  except- 

tracts,  the   lateral    pyramidal    tracts,  .  .1^1  1  Jl     C'     ^j. 

thedirectcerebellartractsandGower's  mg  that  hC  WaS  mUCh  mOrC  QenCient 
(antero-lateral  ascending)  tracts.  ^. 

mentally. 

Diagnosis.  Ataxia  developing  in  childhood,  beginning 
in  the  legs  and  extending  upward,  later  with  disorders  of 
speech  and  loss  of  deep  reflexes,  without  anesthesia  or  sphinc- 
ter trouble,  constitute  a  group  of  symptoms  which  render 
the  diagnosis  of  Friedreich's  (hereditary)  ataxia  unmistak- 
able. 

Prognosis.  The  affection  is  very  slowly  progressive  but 
death  often  results  from  intercurrent  disease. 

Treatment.  Treatment  is  unavailing  except  to  palliate 
the  symptoms  as  they  arise.  The  frequent  club-foot  deformi- 
ties may  be  benefited  surgically. 


SECTION  III. 

BRAIN. 

The  possibility  of  accurate  diagnosis  of  lesions  of  the  brain 
depends  upon  a  knowledge  of  the  localization  of  its  functions. 
The  following  diagram  illustrates  the  cortical  areas  about 
which  our  knowledge  is  comparatively  definite. 


Fig.  27.    Cortical  Areas. 

The  internal  capsule  is  constituted  by  projection  fibers 
from  the  cortex,  by  sensory  fibers  from  lower  levels  and  by  the 
fibers  of  the  optic  radiations.  Their  relation  to  each  other 
and  to  the  central  ganglia  bounding  the  capsule  is  shown  in 
Fig.  28.  Lesions  in  or  about  the  capsule  (see  Cases  61-67) 
are  likely  to  lead  to  the  symptom  of  hemiplegia,  because  at 
this  point  the  motor  fibers  to  the  face  and  extremities  are  con- 
centrated in  a  small  area.  It  is  also  apparent  that  sensory 
hemiplegia  or  hemianopsia  may  result  from  lesions  of  the 
dorsal  portion  of  the  dorsal  limb  of  the  capsule. 

153 


154 


CASE   HISTORIES    IN    NEUROLOGY. 


The  twelve  pairs  of  cranial  nerves  are  distributed  as  follows: 
The  first  (olfactory)  and  second  (optic)  are  outgrowths  of 

the  cerebral  hemi- 
spheres ;  the  third  (ocu- 
lomotor) and  fourth 
(trochlear)  arise  from 
the  quadrigeminal  re- 
gion; the  fifth  (trigem- 
inal) from  the  upper 
part  of  the  pons;  the 
sixth  (abducens), 
seventh  (facial)  and 
eighth  (auditory)  from 
the  lower  portion  of 
the  pons  at  its  junction 
with  the  oblongata ;  the 
ninth  (glossopharyn- 
geal) and  tenth  (vagus) 
from  the  upper  oblon- 
gata; the  eleventh 
(spinal  accessory)  and 
the  twelfth  (hypoglossa)  from  the  upper  spinal  cord  and  oblon- 
gata, respectively. 
Their  main  functions 


Fir,.    28.     Internal  Capsule.     Location  of  Tracts. 


are: 


special 


1.  Olfactory - 
nerve  of  smell. 

2.  Optic  —  special 
nerve  of  sight. 

3.  Oculomotor  —  in- 
trinsic and  extrinsic 
muscles  of  the  eye,  ex- 

the    superior 
and     external 
rectus  muscles. 

4.  Trochlear  —  su- 
perior oblique  muscle. 

5.  Trigeminal  —  sen- 
sation to  the  face  and 
motion  to  muscles  of 
mastication. 


cepting 
oblique 


Fig.  29.    Base  of   Brain.     Cranial  Nerves. 


BRAIN.  155 

6.  Abducens  —  external  rectus  muscle. 

7.  Facial  — •  muscles  of  expression   of  the   face. 

8.  Auditory  —  special  nerve  of  hearing  and  equilibration. 

9.  Glossopharyngeal  —  taste,  posterior  portion  of  the 
tongue,  fibers  to  pharynx. 

10.  Vagus — ^  muscles  of  soft  palate,  pharynx  and  larynx, 
and  sensory  and  motor  fibers  to  viscera. 

11.  Spinal  accessory  —  constitutes  probably  main  portion 
of  motor  fibers  to  vagus;  in  its  spinal  portion  supplies  in  part 
the  trapezius  and  sternomastoid. 

12.  Hypoglossal  —  muscles  of  tongue. 

Symptomatology.  Brain  disease  manifests  itself  either  by 
general  symptoms  or  hy  focal  symptoms,  or  by  a  combination 
of  both.  By  general  symptoms  are  understood  those  which 
indicate  disorder  of  the  brain,  regardless  of  the  location  of 
the  lesion,  usually  due  to  increased  intracranial  pressure. 
Of  these,  headache,  nausea  and  vomiting,  choked  disk,  and 
disorder  of  mental  function  are  conspicuous.  By  focal  symp- 
*  toms  are  understood  those  which  point,  through  disturbance 
of  function,  to  definite,  circumscribed  areas  of  the  brain  or 
cord.  Examples  of  such  symptoms  are,  monoplegia  of  cortical 
origin,  hemiplegia,  hemianopsia,  paralysis  of  individual 
nerves,  aphasia,  astereognosis. 

Brain  diseases  are  due  to  the  same  causes  as  are  operative 
in  other  organs,  the  symptoms  naturally  suffering  because  of 
the  peculiar  and  high  degree  of  differentiation  of  cerebral 
function.  Inflammation,  vascular  defects,  faulty  develop- 
ment, degenerations,  traumatism  and  new  growths  are  the 
common  pathological  processes,  leading  to  symptoms  or 
constituting  diseases,  as  illustrated  by  the  following  cases. 

Case  59.  I.,  a  man  of  thirty-five,  had  been  successful  in 
business,  but  for  years  had  been  regarded  as  eccentric.  He 
had  hoarded  his  money,  had  had  a  mania  for  keeping  small 
coins,  and  in  many  other  ways  had  demonstrated  erratic 
behavior.  He  had  been  married  for  eight  years  and  for  five 
his  wife  had  particularly  noticed  his  peculiarities.  For  the 
previous  three  years  he  had  grown  much  worse,  became 
suspicious  of  his  wife,  and  was  extremely  abusive  in  words 
but  not  In  acts.     He  became  doubtful  of  the  trustworthiness 


156  CASE   HISTORIES    IN    NEUROLOGY. 

of  banks,  and  had  therefore  formed  a  habit  of  keeping  large 
amounts  of  money  at  home.  For  example,  he  had  shown 
at  one  time  to  his  friends  $12,000  in  $1,000  bank  notes. 
For  three  years  he  had  taken  an  excessive  amount  of  alcohol, 
estimated  at  a  quart  of  whiskey  a  day,  and  had  done  nothing 
in  the  way  of  work.  Ten  days  before  being  examined  he  had 
had  an  epileptiform  attack  while  in  bed,  from  which  a  slight 
right  paresis  resulted,  transient  in  character.  He  had  become 
increasingly  difficult  to  get  on  with  and  had  become  so  threat- 
ening that  his  wife  was  afraid  to  remain  in  the  house  with  him. 
Evidence  of  syphilis  was  not  obtained. 

Examination  showed  a  stalwart  man,  evidently  demented. 
His  speech  was  very  thick  and  extremely  confused.  It  was 
entirely  impossible  for  him  to  repeat  a  test  sentence  ("  Third 
riding  regiment  of  light  artillery  ").  He  declined  to  attempt 
to  repeat  the  alphabet ;  he  was  doubtful  about  simple  mathe- 
matical complications;  he  was  unable  to  write  his  own 
name  correctly;  he  said  that  February  had  28  days  in  leap 
year  and  30  at  other  times.  He,  however,  knew  the  day  of 
the  week,  the  month  and  the  year.  The  pupils  were  equal 
and  responded  normally  to  light.  The  knee  jerks  were  normal, 
the  heart  negative ;  pulse,  116;  blood  pressure,  140.  He  had 
taken  no  alcohol  for  ten  days.  In  general  he  had  small 
mental  grasp,  as  indicated  in  the  foregoing  history,  but  in  the 
course  of  conversation  showed  no  special  grandiose  ideas. 

Diagnosis.  The  diagnosis  of  Dementia  Paralytica  was  made 
in  this  case.  It  is  evident,  however,  that  the  element  of  al- 
cohol complicates  the  situation.  In  such  cases  it  is  important 
to  determine,  if  possible,  whether  over-indulgence  in  alcohol 
is  a  cause  or  an  effect  of  the  mental  state.  In  this  instance, 
the  evidence  pointed  to  the  fact  that  he  had  begun  to  dete- 
riorate mentally  before  he  had  taken  so  excessively  to  drink. 
On  the  other  hand,  the  symptoms  were  not  incompatible 
with  the  maudlin  state  to  which  continuous  over-indulgence  in 
drink  leads.  In  favor  of  alcohol  as  the  etiological  factor, 
is  the  fact  that  the  pupils  were  normal  and  the  knee  jerks 
neither  unduly  exaggerated  nor  diminished.  Over  against  this, 
and  more  weighty  as  evidence,  must  be  placed  the  perfectly 
characteristic  speech  defect,  the  epileptiform  seizure,  followed 


BRAIN.  157 

by  temporary  paresis  of  the  right  side  and  the  persistent  signs 
of  dementia  in  spite  of  the  fact  that  no  alcohol  had  been 
taken  for  ten  days.  In  such  doubtful  cases  it  is  desirable 
to  determine  the  presence  or  absence  of  syphilis  by  the  Was- 
sermann  test,  both  in  the  blood  and  spinal  fluid.  The  count 
of  the  cells  in  the  spinal  fluid  is  also  of  significance  as  a 
definite  diagnostic  criterion.  Grandiose  ideas  are  highly 
suggestive  of  dementia  paralytica;  their  absence,  however, 
should  never  preclude  that  diagnosis. 

Prognosis.  The  outcome  of  dementia  paralytica  is 
invariably  fatal.  Under  proper  care  at  a  hospital  to  which 
the  patient  was  sent,  life  may  be  prolonged  for  several  years. 
Remissions  may  occur  but  are  not  frequent. 

Treatment.  Careful  nursing  is  essential.  Antlsyphilitic 
treatment  in  a  well-developed  case  such  as  this  accomplishes 
nothing. 

Note.  Eight  months  later,  the  patient  was  still  at  the 
hospital,  gradually  growing  worse.  Delusions  of  grandeur 
had  become  Increasingly  apparent  and  he  was  more  excited. 
The  hospital  diagnosis  was  dementia  paralytica. 


158  CASE   HISTORIES   IN    NEUROLOGY. 

Case  60.  C,  an  unmarried  man  of  thirty-five,  had  been 
at  a  hospital  for  the  insane  for  a  period  of  two  years,  ten  years 
before  being  seen.  The  diagnosis  of  his  condition  at  that  time 
is  not  known.  He  had  for  some  time  suffered  from  a  chronic 
intestinal  catarrh  and  a  certain  amount  of  cystitis.  He  had 
in  the  past  years  fallen  from  a  weight  of  190  to  140.  He  had 
been  constantly  under  the  care  of  physicians  and,  in  general, 
had  improved.  In  April,  1900,  he  was  found  unconscious 
at  his  office  with  a  slight  cut  over  the  left  eye.  He  had  a  series 
of  convulsions  and  was  taken  to  a  hospital,  where  the  diag- 
nosis of  uremic  poisoning  was  made.  He  entirely  recovered 
from  this  condition  and  was  apparently  as  before,  excepting 
that  he  suffered  considerable  pain  and  for  six  months  past 
had  foolishly  boasted  of  the  amount  of  money  he  had  made. 
Two  days  before  being  examined,  he  had  been  found  in  his 
room,  swearing,  garrulous  and  evidently  mentally  disordered. 
He  failed  to  recognize  people,  and  there  was  slight  twitching 
of  the  face,  which  resulted  in  a  definite  convulsion  limited  to 
the  right  side,  of  slow  onset  and  associated  with  complete 
loss  of  consciousness.  The  convulsive  attack  lasted  about  two 
hours,  during  which  he  passed  urine  involuntarily.  In  the 
afternoon  of  the  same  day,  there  was  further  twitching  of 
the  muscles  of  the  face  on  the  right,  and  also  of  the  tongue. 
He  apparently  improved  during  the  evening,  but  the  next 
morning  was  unable  to  write,  although  he  could  copy.  As 
time  went  on,  he  became  clearer  mentally,  was  able  to  under- 
stand better,  but  could  not  speak  clearly.  He  was  also  unable 
to  swallow  properly. 

When  examined  on  August  26,  the  patient  had  a  dull, 
stupid  expression  with  a  strong  inclination  to  emotionalism. 
There  was  still  a  slight  palsy  of  the  hypoglossal  nerv^e,  and 
of  the  facial  on  the  right  side.  The  pupils  were  slightly 
unequal,  irregular,  the  left  larger  than  the  right,  with  very 
poor  light  reaction  and  retained  accommodation.  There  was 
no  history  of  diplopia  at  any  time  and  no  headache.  The  hand 
grasp  was  about  equal  on  the  two  sides  and  any  previous 
paralysis  of  the  leg  had  disappeared.  The  knee  jerks  were 
not  obtainable.  His  speech  was  markedly  defective,  due 
apparently,  In  part,  to  his  mental  state  and  in  part  to  the 


BRAIN.  159 

remaining  paresis  of  the  twelfth  and  seventh  nerves.  He 
was  able  to  name  objects  readily  and  to  answer  correctly 
a  written  question.  He  was  also  able  to  read,  but  mispro- 
nounced many  words.  When  asked  to  v/rite  his  name  he 
succeeded  in  doing  so  somewhat  imperfectly.  When  given 
a  dictation  he  was  confused  and  failed  to  accomplish  what  was 
asked.  He  wrote  the  alphabet  laboriously  and  with  the  omis- 
sion of  several  letters.  He  copied,  however,  easily  and^quickly. 
He  was  voluble  in  conversation  and  understandable  when 
answering  questions  or  saying  very  simple  things.  In  describ- 
ing his  plans  he  was  almost  unintelligible  and  used  many 
wholly  meaningless  words. 

From  this  time  he  improved  steadily  in  some  respects. 
He  had  no  further  convulsive  seizures,  the  facial  paralysis 
practically  recovered;  the  aphasic  disturbance  disappeared, 
but  this  was  followed  by  a  very  characteristic  and  marked 
speech  defect  in  which  words  were  slurred  and  a  general 
slovenliness  of  diction  supervened.  He  talked  extravagantly 
on  many  subjects,  misspelled  words  of  any  length,  was  childish 
in  manner  and  at  times  emotional.  On  one  occasion,  he 
wrote  as  follows:  "  Have  passed  a  fine  and  good  night; 
a  fine  day  before  me;  read  aloud;  things  going  well;  expect 
to  get  perfectly  well;  will  live  the  best  and  most  perfect 
I  can  after,  and  make  all  who  know  me  happy."  The  knee 
jerks  returned  and  were  active,  but  no  clonus  developed. 
He  became  increasingly  demented,  gained  somewhat  in  weight 
but  developed  no  definite  delusions.  He  had  a  marked  sense 
of  well-being  and  had  many  schemes  for  the  future.  He  was 
committed  to  a  hospital,  grew  rapidly  worse  with  increasing 
speech  defect  and  died  some  months  later  in  a  condition  of 
deep  dementia.    The  autopsy  confirmed  the  diagnosis. 

Diagnosis.  This  patient  had  Dementia  Paralytica.  In 
all  cases  of  convulsive  seizure  or  apoplectiform  attack,  particu- 
larly if  associated  with  transient  cerebral  defects  of  the  nature 
of  aphasia  or  passing  unilateral  paralysis,  the  diagnosis  of 
dementia  paralytica  should  be  seriously  considered.  In  this 
instance,  many  months  elapsed  before  this  decision  was 
reached,  on  account  of  the  misinterpretation  of  the  con- 
vulsive  seizures.      Had   the   whole   situation   been   properly 


l60  CASE   HISTORIES    IN    NEUROLOGY. 

considered  by  the  physicians  who  saw  him,  particularly 
the  condition  of  the  pupils  and  the  mental  state,  such  an 
error  could  hardly  have  been  made.  The  case,  therefore, 
admirably  illustrates  the  diagnostic  value  of  seizures  in  demen- 
tia paralytica  as  well  as  the  error  to  which  these  seizures  may 
lead.  The  Argyll-Robertson  pupil,  with  few  exceptions, 
occurs  only  in  this  condition  and  in  tabes.  Its  presence  is, 
therefore,  as  in  this  case,  of  extreme  diagnostic  value  and 
should  always  lead  to  a  careful  investigation  of  the  mental 
state. 

Prognosis.  Dementia  paralytica  is  a  progressive  and  fatal 
disease,  although  the  suggestion  has  recently  been  made  that 
if  treated  in  the  very  early  stages  it  may  be  aborted  or  cured. 
The  course  of  this  case  was  somewhat  rapid  toward  the  end, 
but  it  is  not  to  be  questioned  that  the  patient  was  suffering 
from  the  disease  for  a  year  or  more  before  the  diagnosis  was 
definitely  made.  The  usual  term  of  life  is  from  three  to  seven 
years. 

Treatment.  Beyond  general  hygiene  and  nursing,  prefera- 
bly at  a  hospital,  treatment  is  unavailing. 


BRAIN.  .  l6l 

Case  6i.  A.,  a  man  twenty- two  years  old,  on  the  night 
of  September  15,  1910,  passed  two  men  In  a  dark  place, 
who  were  fighting  with  knives.  One  of  the  contestants 
ran,  and  the  other  pursuing  him  mistook  A.  for  his  victim 
and  struck  him  a  violent  blow  with  his  knife  over  the  right 
temple  slightly  above  and  in  front  of  the  ear.  The  patient 
did  not  see  the  knife  with  which  he  was  struck  and  was 
entirely  unaware  of  the  approaching  attack  until  he  found 
himself  thrown  to  the  ground.  The  knife  was  withdrawn 
and  the  patient  was  able  to  get  to  his  house,  which  was  in  the 
immediate  neighborhood.  When  he  reached  the  house, 
he  fell  to  the  floor  bleeding  but  still  conscious.  He  was  then 
taken  to  a  hospital.  At  first,  the  blood  spurted  from  the 
wound  but  stopped  spontaneously  before  he  was  taken  to 
the  hospital.  He  lost  consciousness  for  a  period  of  about  two 
days. 

The  immediate  effect  of  the  injury  was  a  paralysis  of  the 
whole  left  side,  with  temporary  numbness  of  the  hand  and  arm. 
He  had  no  speech  defect,  no  pain,  no  headache  and  no  vomit- 
ing. Except  for  the  paralysis  of  the  right  side,  he  made  a 
satisfactory  recovery.  Fragments  of  bone  were  removed  at 
the  hospital,  but  no  detailed  investigation  of  the  brain  was 
made.  He  has  not  been  able  to  walk  since  the  injury.  Ex- 
amination showed  a  depressed  scar  with  loss  of  bone  about 
one  inch  in  length  at  the  position  stated  above.  The  eye 
grounds  were  normal  and  the  cranial  nerves  not  involved, 
except  possibly  the  facial  muscles  on  the  affected  side,  to  a 
very  slight  degree.  The  left  arm  was  practically  helpless, 
contractured  and  with  exceedingly  active  reflexes;  wrist 
clonus  was  easily  obtained.  The  leg  was  likewise  useless 
and  in  a  similar  high  degree  of  spastic  contracture.  The 
slightest  Irritation  was  sufficient  to  produce  violent  clonus. 
The  BabinskI  reflex  was  present  on  the  left,  not  on  the  right. 
There  was  no  discoverable  disorder  of  sensation.  The  patient 
later  had  several  epileptiform  attacks,  which,  however, 
were  not  localized.  Beyond  this  fact,  his  condition  remained 
essentially  unchanged. 

Diagnosis.  In  this  case  It  seems  evident  that  the  knife 
thrust  passed  Inward  toward  the  posterior  limb  of  the  Inter- 


1 62  CASE   HISTORIES    IN    NEUROLOGY. 

nal  capsule  on  the  right  side,  reaching  to  the  immediate 
neighborhood  of  the  motor  fibers,  but  presumably  not 
directly  severing  them,  since  the  patient  was  able  to  walk 
a  considerable  distance  to  his  house  before  falling,  paralyzed. 
This  paralysis  was  presumably  due  to  an  extension  of  Hemor- 
rhage. It  is  probable  that  the  knee  of  the  capsule  was  not  in- 
vaded, since  the  face  was  largely  spared,  nor  was  the  posterior 
portion  of  the  capsule  involved,  since  sensation  was  unaffected. 
It  is  unlikely,  from  the  character  of  the  injury,  the  rapid  on- 
set of  hemiplegic  symptoms  and  from  the  unquestionable 
fact  that  the  knife  penetrated  the  substance  of  the  brain, 
that  the  patient  suffered  a  meningeal  hemorrhage,  which 
also,  without  operative  interference,  would  almost  inevitably 
have  proved  fatal.  Such  an  injury  to  the  capsule  as  this, 
with  the  resultant  symptoms,  not  infrequently  results  from 
bullet  wounds;  but  it  is  probably  a  unique  history  that  such 
a  clean-cut  hemiplegia  as  developed  in  this  case  should  be 
due  to  a  stab  wound. 

Prognosis.  The  outlook  for  recovery  of  function  of  the 
affected  side  is  extremely  small. 

Treatment.  Operation  was  considered  in  this  case,  particu- 
larly after  the  development  of  epileptic  seizures.  Such 
a  procedure,  with  exploration  of  the  cortex  immediately  in 
the  neighborhood  of  the  wound,  would  have  been  justified; 
but,  owing  to  a  certain  difference  of  opinion,  was  not  at- 
tempted. A  relief  of  the  paralysis  could  certainly  not  have  been 
secured  by  this  means. 


BRAIN.  163 

Case  62.  L.,  a  married  man  of  fifty-eight,  had  worked 
hard  and  in  recent  years  had  had  many  anxieties  because 
of  business  reverses,  and  the  death  of  his  wife  and  various 
relatives.  About  four  months  before  being  seen  there  was 
sudden  sHght  loss  of  power  of  the  right  side ;  he  dragged  his 
foot  somewhat  in  walking,  but  recovered  in  great  measure 
and  returned  to  active  business  life.  About  three  months 
later  he  had  an  attack  of  disturbed  breathing  of  the  Cheyne- 
Stokes  type,  from  which  he  completely  recovered.  Three  days 
before  being  seen  he  suffered  a  paralysis  of  the  right  side, 
involving  the  face  to  some  degree;  when  he  recovered  con- 
sciousness there  was  practically  complete  loss  of  speech, 
with  marked  Cheyne-Stokes  respiration  and  general  signs 
of  "distress.  The  urine  for  some  time  had  had  a  slight  trace 
of  albumin,  which  was  inconstant;  repeated  analyses  were 
made. 

On  examination  the  pupils  were  equal  in  size,  and  reacted 
well  to  light;  there  was  slight  paresis  of  the  lower  branches 
of  the  facial  nerve  on  the  right  side,  with  practically  complete 
paralysis  of  the  right  arm  and  leg.  The  knee  jerks  were 
both  present,  and  essentially  alike;  but  there  was  a  Babinski 
response  on  the  right  in  contrast  to  a  normal  plantar  reflex 
on  the  left.  The  heart  apex  was  one  inch  outside  the  nipple 
line;  the  sounds  were  somewhat  muffled;  the  second  aortic 
was  accentuated;  there  was  no  edema.  The  breathing  was 
labored,  and  there  was  some  mucus  in  the  throat;  he  was, 
however,  able  to  take  food  to  a  certain  degree  by  the  mouth. 
He  smiled  at  times  and  appeared  vaguely  to  recognize 
what  was  going  on  about  him.  His  capacity  to  speak  was, 
however,  lost  —  aphasia  of  the  so-called  motor  type.  The 
pulse  was  100,  compressible  but  full;  there  was  no  palpable 
arterial  sclerosis;  the  pressure  was  not  taken.  He  had 
apparently  improved  slightly  since  the  attack,  but  died  four 
days  after  being  seen,  with  a  rising  respiration  and  tempera- 
ture, together  with  vomiting. 

Diagnosis.  Without  a  post-mortem  examination,  which 
was  not  obtained  in  this  case,  it  is  impossible  to  state  with 
definiteness  the  nature  of  the  pathological  process  causing 
the  Apoplexy.     In  view  of  the  renal  complication,  however, 


164  CASE  HISTORIES   IN   NEUROLOGY. 

with  its  accompanying  vascular  disturbances,  it  may  be  pre- 
sumed that  the  paralysis  was  due  to  Hemorrhage  in  and  about 
the  internal  capsule,  rather  than  to  softening  of  the  cerebral 
substance,  through  thrombosis  or  embolism.  The  diagnosis 
of  hemorrhage  is  also  favored  by  the  fact  that  the  final 
attack  was  of  sudden  onset.  The  ultimate  clinical  signs  are 
the  same  in  either  case ;  namely,  a  unilateral  paralysis,  usually 
associated  with  motor  aphasia,  If  the  lesion  be  on  the  left 
side  of  the  brain,  with  partial  sparing  of  the  upper  branch 
of  the  facial  nerve,  due,  presumably,  to  its  bilateral  cerebral 
representation. 

Prognosis.  This  case  was  hopeless  from  the  outset. 
The  brain  disturbance  of  itself  was  no  doubt  extensive  enough 
to  lead  to  death,  and  this  with  an  undoubted  interstitial 
nephritis  rendered  the  outcome  doubly  discouraging. 

Treatment.  The  patient  was  made  comfortable  in  the 
hope  that  nature  might  still  be  able  to  overcome  the  shock 
to  which  the  brain  was  subjected.  In  general  the  treatment 
of  cerebral  apoplexy,  in  view  of  the  fact  that  a  positive 
determination  between  hemorrhage  and  softening  is  rarely 
possible,  must  be  expectant.  In  cases  of  high  arterial  tension, 
blood  letting  is  occasionally  justified,  together  with  sedatives, 
of  which  bromides  may  be  taken  as  examples.  An  attempt 
to  reduce  the  pressure  by  the  nitrites  is  a  questionable  pro- 
cedure in  view  of  the  fact  that  a  diminution  of  general  pres- 
sure may  well  tend  to  increase  of  the  outflow  of  blood  from 
the  ruptured  artery,  presuming  a  hemorrhage  to  have  oc- 
curred. It  is  probable  that  nature  manages  the  situation 
wisely.  If,  on  the  other  hand,  there  is  strong  evidence  of  weak 
heart  action  and  a  failing  pulse,  leading  to  the  supposition 
that  softening  rather  than  hemorrhage  has  occurred  in  the 
brain,  heart  stimulation  is  justified  by  means  of  strychnia, 
caffeine  or,  under  certain  circumstances,  digitalis,  best  given 
in  the  form  of  digipuratum. 


BRAIN.  165 

Case  63.  C,  a  woman  of  fifty-two  and  unmarried,  had 
never  regarded  herself  as  well;  she  had  suffered  from  what 
she  called  "  fainting  "  when  young,  and  palpitation  of  the 
heart;  she  had  been  careless  about  her  diet,  and  had  recently 
had  an  attack  of  "  sore  throat  "  which  had  resulted  in  peri- 
tonsillar abscess.  On  June  4,  while  at  dinner,  she  noticed 
that  her  right  hand  began  to  feel  numb;  the  sensation 
extended  to  her  forearm;  she  was  disturbed,  and  started 
to  rise  from  the  table,  but  sank  back  and  rapidly  became 
unconscious,  with  the  development  of  a  right-sided  paralysis 
within  the  space  of  ten  or  fifteen  minutes.  At  first  she  was 
able  to  speak,  but  not  intelligibly;  for  half  an  hour  she  could 
be  roused,  but  two  hours  after  the  onset  she  became  absolutely 
unconscious  and  so  remained,  with  slight  intermissions, 
for  a  period  of  twelve  hours.  Thereafter  there  was  some 
improvement. 

When  examined  on  June  11,  one  week  after  the  onset, 
she  was  entirely  conscious,  but  with  very  marked  disturbance 
of  speech,  and  slight  difificulty  in  comprehension.  The  defect 
was  chiefly,  however,  on  the  side  of  enunciation,  associated 
with  much  paraphasia;  she  had  difficulty  in  repeating  and 
reading  aloud,  often  misused  words,  and  named  objects 
very  imperfectly;  there  had,  however,  been  distinct  improve- 
ment in  this  during  the  week  of  her  illness.  The  pupils  were 
small,  with  good  light  and  accommodative  reaction,  and  normal 
fields.  The  outlines  of  the  optic  disks  were  indistinct  but 
there  was  no  defined  swelling.  The  right  facial  nerve  showed 
slight  weakness ;  other  cranial  nerves  were  free  from  disturb- 
ance; the  right  arm  was  completely  paralyzed;  the  reflexes 
somewhat  active,  with  unimpaired  sensibility;  the  right 
abdominal  reflex  was  lacking.  There  was  also  complete  pa- 
ralysis of  the  right  leg,  the  right  knee  jerk  was  more  pro- 
nounced than  the  left;  ankle  clonus  was  indicated  and  there 
was  a  Babinski  response  on  the  right,  together  with  a  more 
active  Achilles  than  on  the  other  side.  The  sensation  of  the 
right  leg  was  delayed  and  blunted;  the  heart  showed  no 
lesion;  the  pulse  was  84  and  weak;  the  pressure,  upwards 
of  170;  the  patient  was  rather  pale  in  appearance,  and  of 
slender  build. 


1 66  CASE    HISTORIES    IN    NEUROLOGY. 

Diagnosis.  The  presumable  lesion  in  this  case  was 
Cerebral  Softening  in  the  usual  distribution  of  the  branches 
of  the  middle  cerebral  artery,  rather  than  hemorrhage. 
As  in  Case  62,  however,  nothing  dogmatic  may  be  said  on  this 
point.  AA'eight  is  simply  lent  to  the  assumption  by  the  fact 
that  there  was  a  distinct  prodromal  period,  characterized 
by  sensations  of  numbness,  and  apprehension,  followed  by 
gradual  loss  of  consciousness,  which  did  not  become  complete 
for  two  hours.  Such  an  onset  suggests  thrombus  formation 
rather  than  hemorrhage.  The  rather  weak  heart  action, 
as  indicated  by  the  pulse,  is  further  evidence  in  favor  of  soften- 
ing. The  lesion  involved  the  left  internal  capsule  at,  or  about, 
the  region  of  the  knee,  since  sensation  was  largely  though 
not  entirely  spared.  The  absence  of  the  abdominal  reflex 
on  the  side  of  the  paralysis  is  a  valuable  diagnostic  sign. 

Prognosis.  The  patient  continued  to  improve.  With  care 
there  is  no  reason  why  she  should  not  recover  a  high  degree 
of  usefulness,  although  the  spastic  weakness  of  the  right 
side  will  not  entirely  disappear,  and  the  speech  is  likely 
to  remain  faulty. 

Treatment.  Rest  in  bed,  care  of  the  bowels,  a  nutritious, 
simple  diet,  and  general  heart  stimulation  were  prescribed 
in  this  case. 


BRAIN.  167 

Case  64.  A.,  a  man  of  sixty-eight,  married,  without  occu- 
pation for  several  years,  had  considered  himself  well  up  to 
July,  1906.  At  that  time  he  was  obliged  to  be  in  the  hot  sun 
for  several  days,  following  which  he  woke  one  morning  with 
a  feeling  of  numbness  in  two  of  the  fingers  of  the  left  hand, 
which  gradually  extended  to  the  arm.  (See  Case  63.)  At 
the  end  of  two  or  three  days  he  lost  all  strength  in  that  arm; 
the  leg  was  not  then  affected.  He  had  massage  during  the  sum- 
mer and  improved  very  considerably.  On  March  31  of  the 
following  year,  he  had  a  second  attack,  affecting  the  left  side, 
arrrr  and  leg.  From  this  he  again  improved.  Two  months 
later  he  had  a  third  attack,  and  since  then  up  to  the  time  when 
he  was  seen  in  July,  1907,  he  had  had  a  number  of  slight 
seizures  associated  with  convulsive  movements.  He  felt 
weaker  after  each  of  these  attacks,  and  suffered  from  "  jerk- 
ing "  of  the  arm  and  leg,  which  exhausted  him  greatly.  His 
appetite,  however,  had  remained  good,  and  his  sleep  was  satis- 
factory. His  chief  annoyance  at  this  period  were  frequent 
slight  convulsive  attacks  involving  the  arm  and  leg. 

Examination  showed  the  right  pupil  to  be  slightly  smaller 
than  the  left,  with  adequate  light  response  and  defective 
accommodation,  as  often  seen  in  persons  of  his  age.  The 
tongue  was  protruded  to  the  left;  the  sensation  of  the  face 
was  normal;  paralysis  of  the  face  was  not  noticeable;  the 
speech  was  slightly  disturbed,  somewhat  thick  and  lisping, 
but  he  never  lost  the  capacity  to  speak. 

The  heart  impulse  could  not  be  felt  through  the  chest  wall ; 
the  sounds  were  faint,  with  probable  slight  accentuation 
of  the  second  aortic.  The  pulse  was  84,  regular,  compressible 
and  without  sign  of  definite  radial  sclerosis.  The  left  arm 
was  weak  in  all  of  its  movements,  and  there  was  considerable 
edema  of  the  left  hand;  sensation  both  of  arm  and  leg  was 
normal.  All  the  arm  reflexes  on  the  left  were  increased ; 
the  abdominal  reflex  on  that  side  was  lost.  The  left  leg  showed 
very  slight  weakness,  with  a  slight  increase  of  the  knee  jerk 
and  without  Babinski;  there  was  no  edema,  and  the  patient 
made  no  special  complaint  of  the  leg,  except  that  he  had  an 
extremely  slight  limp.  He  had  taken  alcohol  in  some  form 
for  years,  but  never  in  great  amount. 


1 68  CASE   HISTORIES    IN    NEUROLOGY. 

This  patient  was  seen  again  six  months  later;  during  the 
inter\'ening  period  there  had  been  a  distinct  increase  of  the 
left-sided  weakness.  The  face  was  still  unaffected;  the 
left  arm  was  extremely  weak,  slight  movements  in  the  fingers 
only  being  possible;  the  arm  reflexes  were  increased;  sen- 
sation was  still  normal ;  the  pulse  rate  was  76,  slightly  irregu- 
lar; the  heart  sounds  fairly  clear,  without  murmurs,  and  with- 
out definite  accentuation  of  the  second  aortic.  The  left  leg 
could  be  moved  in  some  degree;  the  knee  jerk  was  active; 
the  Babinski  response  definite;  Achilles  active;  clonus 
indicated.  The  right  leg  was  normal.  It  was  of  interest  that 
an  attempt  to  close  the  fingers  of  the  affected  hand  induced 
flexion  movements  of  the  toes  of  the  same  side  ("Mit- 
bewegimg  "). 

Examination  of  the  urine  showed  a  normal  amount  in  the 
twenty-four  hours,  specific  gravity  1,015,  acid,  no  sugar,  no 
albumin. 

Diagnosis.  The  interest  of  this  case  centers  in  the  fact 
of  its  gradual  onset,  ultimately  resulting  in  a  high  degree 
of  paralysis  of  the  left  arm  and  leg,  with  almost  complete 
sparing  of  the  face.  This  type  of  Apoplexy  is  not  unusual, 
and  is  doubtless  to  be  attributed  to  a  cerebral  vascular  dis- 
order dependent  upon  imperfect  circulation,  presumably 
due  directly  to  gradual  occlusion  of  vessels  supplying  the 
capsule  and  its  neighborhood. 

Prognosis.  In  cases  of  this  type  of  gradual  onset,  asso- 
ciated with  preliminary  signs  of  irritation,  spasm  and  the 
like,  followed  by  weakness  and  ultimately  paralysis,  the  out- 
look is  always  grave.  In  a  period  of  about  a  year  and  a  half 
this  patient  underwent  these  various  stages,  beginning  with 
an  apparently  trifling  numbness  of  one  hand,  and  ending 
with  an  essentially  complete  paralysis  of  arm  and  leg. 

Treatment.  In  spite  of  heart  stimulation  and  general 
hygiene,  the  process  could  not  be  checked. 


BRAIN.  169 

Case  65.  S.,  a  married  woman  of  thirty-one,  three  years 
before  had  had  a  stillborn  child;  she  had,  however,  been  well 
up  to  the  birth  of  a  second  child  two  weeks  ago.  The  labor 
was  long  and  arduous;  instruments  were,  however,  not  re- 
quired, and  her  illness  had  been  in  no  way  unusual  until  the 
day  before  being  seen.  It  was  then  noticed  that  she  was  moan- 
ing in  her  sleep,  and  when  spoken  to  she  continually  said, 
"  I  can't  help  it."  There  was  some  contortion  of  the  face, 
but  no  general  convulsion;  later  she  was  able  to  nurse  her 
baby;  the  following  day  she  was  apathetic  and  disinclined 
to  speak;  she  appeared  to  be  drowsy,  and  yawned  continually; 
the  tendency,  however,  was  toward  improvement. 

Examination  showed  the  pupils  to  be  slightly  unequal, 
dilated,  the  right  larger  then  the  left,  with  retained  reaction 
to  light  and  distance ;  there  was  a  very  slight  facial  asymmetry, 
the  right  side  being  affected.  This,  however,  was  not  notice- 
able on  voluntary  movement,  such,  for  example,  as  showing 
the  teeth;  there  was  no  other  cranial  nerve  involvement. 
The  right  arm  was  moved  less  well  than  the  left;  but  weak 
movements  were  still  possible.  The  arm  reflexes  were  the 
same  on  the  two  sides;  no  abdominal  reflex  was  obtained  on 
either  side ;  the  right  leg  was  decidedly  weaker  than  the  left, 
corresponding  to  the  condition  of  the  arm.  The  knee  jerks 
were  present,  slight  on  both  sides,  and  apparently  equal. 
There  was  no  ankle  clonus,  and  no  Achilles  response;  there 
was,  however,  a  definite  Babinski  reaction  on  the  right, 
with  a  marked  normal  plantar  on  the  left;  the  sensibility 
of  the  face,  arm  and  leg  was  unimpaired.  The  heart  sounds 
were  normal;  the  second  aortic  sound  was  not  exaggerated, 
and  there  was  no  apparent  radial  sclerosis.  The  pulse  was 
100,  and  regular  in  time.  Speech  was  markedly  affected; 
simple  commands  were  in  general  understood ;  but  a  request, 
for  example,  to  put  out  her  tongue  resulted  merely  in  open- 
ing the  mouth.  She  had  an  extremely  small  vocabulary  and 
presented  a  typical  picture  of  so-called  motor  aphasia. 

Diagnosis.  Owing,  no  doubt,  to  the  vascular  strain 
incurred  during  pregnancy  and  childbirth  a  cerebral  vessel 
in  the  neighborhood  of  the  left  internal  capsule  involving  the 
lenticular  zone  and  presumably  Broca's  convolution   (third 


I/O  CASE   HISTORIES    IN    NEUROLOGY, 

left  frontal)  was  ruptured,  leading  to  a  right  Hemiplegia 
of  moderate  degree.  The  importance  of  the  Babinski  sign 
is  well  demonstrated  by  this  case. 

Prognosis.  Improvement  will  occur  without  complete 
restoration  of  the  function  of  the  affected  side. 

Treatment.  The  treatment  is  essentially  to  give  natural 
processes  the  best  opportunity  possible;  to  this  end  nursing 
of  the  baby  should  be  stopped;  rest,  both  physical  and  men- 
tal, required,  and  such  drugs  given  as  the  condition  of  the 
circulation  demands,  as  described  in  previous  cases. 


BRAIN.  171 

Case  66.  E.,  a  child  of  ten,  had  not  been  well  since  her 
fourteenth  month.  She  was  a  second  child;  the  birth  was 
easy,  and  for  the  first  year  of  her  life  she  had  been  well ;  when 
about  fourteen  months  old,  after  a  violent  attack  of  coughing, 
following  measles  and  bronchitis,  she  had  had  a  severe  con- 
vulsive attack,  with  subsequent  left  hemiplegia.  Two  days 
later  the  convulsions  recurred  with  increasing  violence  and 
lasted  for  a  period  of  hours.  From  that  time  on  the  patient 
had  recurring  attacks  of  conjugate  eye  deviation  toward  the 
right,  accompanied  by  attacks  resembling  petit  mal.  The 
original  hemiplegia  improved  to  a  certain  degree.  For  several 
years  the  convulsive  seizures  were  infrequent;  but  later,  and 
up  to  the  time  of  examination,  the  attacks  had  increased  in 
frequency  and  had  assumed  a  distinct  epileptiform  character. 
The  child  did  not  talk  until  three,  and  at  school  had  remained 
one  year  behind. 

Examination  showed  normal  pupils.  There  was  a  definite 
left  hemiplegia,  sparing  the  face,  accompanied  by  a  strong 
tendency  to  athetoid  movements  of  the  hand.  She  limped 
somewhat.  Mentally  she  was  clear,  so  far  as  could  be  deter- 
mined by  a  somewhat  superficial  examination. 

Under  a  moderate  treatment  with  the  bromides,  the 
attacks  for  which  she  chiefly  sought  advice  were  distinctly 
modified.  She  seldom  fell,  but  continued  to  have  seizures 
of  petit  mal.  She  later  became  irritable  and  somewhat 
debilitated ;   her  subsequent  history  is  not  known. 

Diagnosis.  This  case  is  to  be  regarded  as  one  of  Infantile 
Hemiplegia  associated  with  Epilepsy.  It  is  probable  that 
after  violent  coughing,  following  a  double  infection,  a  cortical 
vascular  disturbance  was  induced,  sufficient  in  degree  to 
injure  the  motor  cortex.  The  amount  of  injury  must  have 
been  considerable,  inasmuch  as  a  hemiplegia  resulted,  as 
well  as  convulsions  of  violent  character,  which  later  developed 
into  typical  epileptic  attacks.  It  is  altogether  probable  in 
such  cases  that  the  cause  of  the  epilepsy  is  mechanical,  inas- 
much as  it  is  often  associated  with  a  manifestly  destructive 
lesion,  causing  unilateral  paralysis.  It  should  be  remembered 
that  hemiplegia  in  young  children  is  due,  in  the  great  propor- 
tion of  cases,  to  cortical  lesions  rather  than  to  those  in  and 


172  CASE   HISTORIES    IN    NEUROLOGY. 

about  the  capsule.  The  association  between  early  convulsive 
seizures  and  later  epilepsy  is  illustrated  by  this  case. 

Prognosis.  Improvement  under  treatment  occurred,  and 
should  continue.  The  child,  however,  will  no  doubt  remain 
slightly  handicapped,  both  physically  and  mentally. 

Treatment.  Sodium  bromide  was  given  in  doses  of  from 
10  to  30  grains  daily;  the  diet  was  regulated,  particularly 
with  reference  to  the  use  of  meat.  Under  these  conditions 
the  child  impro\'ed,  but  the  attacks  were  not  completely 
controlled,  although  diminished  in  frequency. 


BRAIN.  173 

Case  67.  H.,  a  woman  of  forty-five,  unmarried,  had  suf- 
fered since  the  age  of  seventeen  with  joint  pain  and  swelling 
of  the  feet,  undoubtedly  rheumatic  in  character;  she  had  at 
various  periods  had  attacks  of  vertigo,  heart  palpitation, 
dyspnea  and,  on  exertion,  orthopnea.  Her  heart  area  was  en- 
larged, and  she  had  long  had  a  presystolic  cardiac  thrill  and 
soufHe.'  She  had  continually  been  in  hospitals  on  account 
of  her  heart  condition.  On  September  5,  1895,  she  had  been 
feeling  poorly,  had  a  slight  fever,  and  took  to  her  bed  on  ac- 
count of  general  weakness.  The  day  following,  while  sitting 
in  a  chair,  she  suddenly  experienced  a  feeling  of  numbness 
and  pain  in  both  legs;  she  was  temporarily  unable  to  walk, 
but  rapidly  improved  after  a  few  days.  On  October  i,  while 
at  breakfast,  she  suddenly  fell  back  unconscious ;  her  face  was 
flushed,  but  her  breathing  was  not  stertorous.  There  was  im- 
mediate paralysis  of  the  right  side,  including  the  face;  she 
partially  recovered  consciousness  in  a  few  hours,  but  suffered 
from  hiccough  and  inability  to  swallow  for  a  period  of  two  days. 
There  was  retention  of  urine  for  three  days,  followed  by  in- 
continence. She  was  also  markedly  aphasic;  but  in  general 
there  was  gradual  improvement  in  the  following  six  weeks. 
She  had  some  pulmonary  edema  which  caused  discomfort 
while  lying  down.  On  December  18,  she  suffered  an  acute 
collapse;  the  skin  was  cold;  pulse,  180,  of  poor  quality,  and 
the  expression  anxious.  There  was,  thereafter,  a  gradual 
development  of  blue  blotches  on  various  parts  of  the  body, 
varying  in  size  from  minute  points  to  areas  as  large  as  a  finger- 
nail. This  was  particularly  marked  on  the  legs  and  the  low^er 
abdomen  up  to  one  inch  above  the  umbilicus.  At  this 
level  there  was  a  definite  line  marking  the  upper  limit  of 
lividity.  This  condition  also  improved,  except  over  the  left 
leg  below  the  knee,  where  the  cyanosis  distinctly  increased. 

On  physical  examination  at  this  time  speech  was  impossible 
and  she  had  some  difficulty  in  expressing  herself  by  sounds. 
Her  understanding  was  also  not  perfectly  clear,  as  shown  by 
the  fact  that  she  could  not  comply  with  a  simple  request, 
such  as  to  show  her  tongue.  The  pupils  reacted  slightly; 
the  pulse  was  irregular,  the  radial  artery  not  noticeably  rigid ; 
the  lungs  were  normal;    the  heart  gave  a  presystolic  thrill 


174 


CASE   HISTORIES    IN    NEUROLOGY. 


at  the  apex;  the  second  pulmonic  sound  was  increased,  and 
there  was  slight  enlargement  to  the  right;  the  spleen  and  liver 
were  normal.  The  left  leg  below  the  knee  and  extending  half- 
way up  the  thigh  was  cold;  the  foot  and  leg  nearly  up  to  the 
knee  were  discolored  to  a  high  degree;  no  pulse  was  felt  in 
the  femoral  artery ;  there  was  no  knee  jerk  on  the  left  side ;  the 
leg  behind  the  knee  was  tender  on  pressure.  The  right  leg 
was  completely  paralyzed,  with  very  active  knee  jerk  and 
slight  ankle  clonus;  the  pulse  could  be  felt  both  in  the  femoral 
and  popliteal  arteries;  the  right  arm  was  also  paralyzed, 
with  contractures  at  the  elbow,  wrist  and  fingers.  The  state 
of  the  patient  was  such  that  a  sensory  examination  could  not 
be  made.  The  blood  showed  4,868,000  red  cells  and  11,000 
white,  with  hemoglobin  73%.  The  urine  gave  a  trace  of 
albumin;  specific  gravity  1,018;  no  sugar;  abundant  hyaline 
and  fine  granular  casts;  a  few  renal  cells;  epithelial  cells, 
leucocytes  and  triple  phosphates. 

She  grew  worse,  and  died  January  16. 

The    autopsy  showed   the   following   conditions:     Chronic 
mitral  endocarditis,  with  stenosis;   slight  aortic  insufficiency; 

dilatation  of  the  left 
auricle,  with  a  throm- 
bus in  the  appendage ; 
embolism  of  the  middle 
cerebral  artery  with 
softening;  embolic  in- 
farction of  the  spleen 
and  kidneys;  embol- 
ism and  thrombosis  of 
the  iliac  arteries;  dry 
gangrene  of  the  left  leg 
below  the  knee. 

Diagnosis.  This 
case  offers  a  peculiarly 
clear  picture  of  definite 
clinical  significance ;  of 
Embolism  consequent 
upon  a  damaged  heart. 
=.  .  .        .  """■ '°"  '''"  '';  ,  f    f.   •  The  patient  had  rheu- 

Shaded  area  shows  approximate  extent  of  soltening.  i^ 


BRAIN.  175 

matism  in  her  early  years  followed  by  various  heart  symptoms, 
which  did  not  reach  the  point  of  danger  until  about  her  fortieth 
year;  she  then  had  a  series  of  disturbances  undoubtedly  due 
to  embolism  arising  from  the  damaged  heart  valves,  with  ac- 
companying thrombosis.  She  finally  suffered  a  definite 
apoplexy*  with  paralysis  of  the  right  side,  and  aphasia,  of 
extremely  sudden  onset,  due  to  embolism  of  the  left  middle 
cerebral  artery.  This  was  followed  by  the  detachment  of 
another  and  no  doubt  larger  embolus,  which  was  temporarily 
stopped  at  the  bifurcation  of  the  aorta  into  the  iliac  arteries, 
as  shown  by  the  bilateral  cyanosis  of  the  legs  reaching  to 
about  the  level  of  the  umbilicus.  Later,  it  was  evident 
that  this  embolus  was  dislodged  and  passed  into  the  artery 
of  the  left  leg,  ultimately  leading  to  gangrene  through  cutting 
off  the  blood  supply,  whereas  the  right  leg  recovered  its 
normal  color.  Death  no  doubt  ultimately  resulted  from  still 
another  embolism.  The  diagnosis  in  this  case,  therefore, 
readily  made  during  life,  was  endocarditis,  embolism  and 
thrombosis,  with  left-sided  cerebral  softening.  These  supposi- 
tions the  autopsy  verified. 

Prognosis.  A  large  part  of  this  patient's  life  was  spent 
in  hospitals,  often  as  a  helper.  It  was  doubtless  due  to  strict 
care  and  close  medical  supervision  that  she  so  long  escaped 
the  fate  which  finally  overtook  her.  The  outcome  of  such 
cases  naturally  depends  upon  the  possibility  of  avoiding 
the  detachment  of  emboli.  No  doubt  a  guarded  life  conduces 
to  this  end;  the  situation,  however,  under  the  best  possible 
conditions,  never  ceases  to  be  threatening. 

Treatment.  The  only  available  treatment  is  prophylaxis. 
In  this  case  the  heart  compensation  had  not  failed,  and  no 
warning  was  given  of  the  possible  detachment  of  emboli. 
When  the  apoplexy  finally  supervened,  little  could  be  done 
beyond  relieving  the  superficial  symptoms  as  they  arose. 
The  general  condition  of  the  patient  did  not  justify  amputa- 
tion of  the  gangrenous  foot. 


176  CASE   HISTORIES    IN    NEUROLOGY. 

Case  68.  I.,  a  man  of  seventy-five,  for  some  years  past  had 
been  gradually  losing  his  mental  grasp  in  the  way  of  showing 
lack  of  initiative,  doubts  and  difficulty  in  keeping  his  mind 
fixed  on  any  special  object,  although  formerly  a  person  of 
great  resources.  Examination  showed  no  objective  physical 
defect  beyond  a  high  blood  pressure,  tortuous  radial  arteries 
and  slightly  disturbed  general  nutrition.  He  was,  however, 
quite  able  to  care  for  himself,  to  go  about  at  first  alone  and 
later  with  an  attendant,  and  in  the  earlier  stages  to  take  a 
certain  interest  in  reading  and  similar  diversions.  He  was 
tormented  continually  by  doubt  as  to  any  given  course  of  ac- 
tion and  spent  much  of  his  time  in  weighing  the  advantages 
of  various  plans  for  his  own  betterment.  During  the  period 
he  was  under  observation,  he  traveled  considerably,  always 
with  scepticism  as  to  its  advisability,  and  became,  as  time  went 
on,  increasingly  unhappy  and  fearful  forhis  mental  equilibrium. 
At  times,  he  had  temporary  periods  of  confusion  in  which  he 
would  for  a  short  period  be  irresponsible  and  do  various  un- 
usual things  quite  out  of  accord  with  his  custom.  He  also 
had  periods  when  speech  was  difficult  and  his  words  were 
confused.  This,  however,  never  amounted  to  a  true  aphasia. 
No  paralysis  developed  and  his  appetite  and  bodily  functions 
remained  essentially  normal  up  to  the  time  of  his  final  acute 
illness.  General  mental  and  physical  failure  were,  however, 
apparent  to  those  about  him.  The  urine  at  no  time  showed 
any  significant  abnormality.  A  sample  examination  follows: 
Twenty-four  hour  amount,  46  ounces;  clear,  acid,  specific 
gravity  1,013,  slightest  possible  trace  of  albumin,  no  sugar, 
no  diacetic  acid,  no  acetone,  very  slight  sediment,  con- 
sisting of  a  rare  squamous  and  small  round  cell  with  no 
pus  or  blood ;  one  coarse  granular  cast  was  found  in  two  slides 
after  long  search. 

One  morning  the  patient  suddenly  became  confused  while 
at  the  breakfast  table.  He  was  at  once  unable  to  walk,  though 
not  definitely  paralyzed.  Speech  was  difficult  and  he  showed 
much  restlessness,  attempting  to  get  up  continually  from  a 
couch  where  he  was  lying.  An  examination  showed  the  pupils 
to  be  equal,  with  a  definite  but  slight  light  reaction;  there  was 
no  facial  paralysis.     The  pulse  was   80,   the    blood  pressure 


BRAIN.  177 

245  or  more.  The  heart  sounds  were  somewhat  obscure  and 
a  definite  accentuation  of  the  second  aortic  sound  could  not 
be  determined.  The  arm  reflexes  were  extremely  active, 
but  there  was  no  paralysis.  The  knee  jerks  were  also  very 
active,  ^as  was  the  Achilles  reflex.  There  was,  however, 
no  Babinski  or  clonus.  He  was  restless  and  confused.  In 
the  afternoon  of  the  same  day  the  pressure  still  remained  high, 
and  a  slight  left  paresis  had  begun.  The  reflexes  as  before 
were  very  active  on  both  sides,  but  no  abdominal  reflex  could 
be  obtained  on  either  side.  Speech  was  very  much  disturbed 
and  practically  unintelligible,  and  his  mind  was  evidently 
confused.  He  grew  gradually  worse  with  a  steady  fall  of 
blood  pressure,  rising  respiration  and  pulse  and  a  constant 
temperature  of  about  101°.  The  reflex  condition  remained 
the  same.  There  was  no  definite  paralysis  at  any  time  and 
the  face  was  apparently  entirely  spared.  Under  these  condi- 
tions he  died,  five  days  after  the  onset  of  the  last  serious 
attack. 

Autopsy.  The  post-mortem  examination  showed  the  body 
organs,  including  the  heart,  in  a  remarkably  normal  condition 
for  a  man  of  his  age,  seventy-nine  years.  The  kidneys, 
for  example,  showed  no  definite  degeneration,  a  matter  of 
interest  in  connection  with  the  terminal  high  blood  pressure. 
The  brain,  on  the  contrary,  had  suffered  greatly  from  arterio- 
sclerotic changes.  The  circle  of  Willis  was  highly  degenerated 
and  the  cortex  showed  some,  though  not  definite,  signs 
of  atrophy.  A  small  hemorrhage  about  one  centimeter  in 
diameter  was  found  in  the  pons,  presumably  the  cause  of  the 
final  attack.  No  other  pathological  lesion  than  that  of  arterio- 
sclerosis was  revealed  to  account  for  the  condition  obser^-ed 
during  the  later  years  of  life. 

Diagnosis.  Such  a  case  may  properly  be  classified  as  Arterio- 
sclerosis. The  autopsy  justified  the  opinion  entertained 
during  life  that  there  was  no  marked  physical  defect  in  the 
central  nervous  system  or  elsewhere  except  that  incident  upon 
old  age  with  its  accompanying  or  causative  arterial  degenera- 
tions. 

Prognosis  and  Treatment.  Life  may  be  prolonged  for 
long  periods  under  conditions  of  extreme  arteriosclerosis  by 


IjS  CASE   HISTORIES    IN    NEUROLOGY. 

scrupulous  care  as  to  diet,  exercise  and  occupation.  Meat 
should  be  curtailed  and  the  dietary  made  both  simple  and 
nutritious;  particular  care  should  be  taken  of  the  bowel 
function,  for  the  regulation  of  which  no  drug  is  so  useful  as 
cascara  sagrada,  either  in  the  form  of  the  fluid  extract  or 
tablets  of  the  extract.  Phosphate  of  soda,  a  teaspoonful, 
best  given  in  hot  water  before  breakfast,  was  found  useful 
in  this  case.  More  important  than  the  drug  treatment  is 
the  general  physical  care,  and  perhaps  even  more  important 
than  that,  certainly  for  the  happiness  of  the  patient,  is  a  tact- 
ful manner  of  preparing  the  troubled  mind  for  its  inevitable 
disabilities. 


BRAIN.  179 

Case  69.  S.,  a  man  approximately  seventy-two  years  old, 
was  seen  November  30,  1906.  The  patient  for  the  most  part 
had  led  a  sedentary  life,  and  for  some  years  past  had  shown 
the  inroads  of  time  by  a  general  failing  in  strength.  Physi- 
cally he  was  handicapped  by  a  marked  curvature  of  the  spine, 
rigidity  of  the  spinal  column  and  of  the  bordering  muscles. 
He  had  presumably  had  two  slight  hemiplegic  attacks  in 
preceding  years,  one  on  each  side,  from  which  he  had  in  general 
recovered. 

Physical  examination  showed  a  high  degree  of  radial 
sclerosis  with  somewhat  weak  heart  sounds.  The  knee  jerks 
were  active,  but  there  was  no  Babinski  phenomenon  and  no 
evidence  whatever  justifying  the  supposition  of  a  systemic 
degeneration  of  the  pyramidal  tracts.  Although  in  general 
he  presented  many  indications  of  advancing  years,  these  were 
wholly  out  of  proportion  to  the  extraordinary  disturbance 
of  gait  from  which  he  suffered  and  which  had  virtually  made 
him  a  prisoner  in  his  house.  There  was  no  paralysis  of  the 
legs,  and  in  general  the  muscular  strength  was  sufficiently 
good.  In  spite  of  this  fact  there  had  been  increasing  difficulty 
in  locomotion,  characterized  by  extreme  difficulty  in  starting, 
a  tendency  to  shorten  the  steps  more  and  more  as  progress 
was  made,  and  the  incapacity  to  make  a  movement  forward 
of  more  than  a  few  inches.  The  patient  was  obliged  often 
to  stop,  after  going  a  few  yards,  tired  with  the  amount  of 
muscular  effort  which  he  had  been  called  upon  to  make. 

The  gait  might  be  properly  enough  described  as  "  stammer- 
ing or  stuttering."  After  once  getting  started,  particularly 
if  helped  by  a  little  moral  suasion,  he  was  able  to  walk  reason- 
ably well  for  a  short  space,  with  steps  of  considerable  length, 
until  the  movement  was  checked  through  sudden  fatigue, 
or  more  probably  through  lack  of  confidence  in  his  capacity 
to  proceed. 

Diagnosis.  In  the  absence  of  adequate  organic  cause  on  the 
part  of  the  nervous  system,  this  patient  may  properly  be 
said  to  be  suffering  from  a  condition  of  Senile  Trepidant 
Abasia  (Charcot). 

Prognosis.  In  view  of  the  age  of  the  patient,  the  condition 
of  the  blood  vessels,  and  the  difficulty  of  overcoming  more  or 


l80  CASE   HISTORIES    IN    NEUROLOGY. 

less  fixed  tendencies  in  the  later  period  of  life,  the  prognosis, 
so  far  as  recovery  of  normal  locomotion  is  concerned,  is  not 
good.  Improvement  may  take  place,  but  complete  recovery 
does  not. 

Treatment  and  Remarks.  This  patient  improved  and  was 
able  to  walk  decidedly  better  under  instruction,  accompanied 
by  a  considerable  degree  of  firmness  and  reassurance  as  to 
his  capacity  in  that  direction.  This  type  of  disturbance  cer- 
tainly demands,  by  way  of  explanation,  something  more  than 
a  physical  cause  for  its  existence,  since  examination  of  such 
patients  shows  no  sufficient  physical  incapacity  to  account 
for  the  gait.  There  is  no  paralysis;  movements  in  other  posi- 
tions may  be  made  with  comparative  ease  and  freedom;  the 
individual  muscular  movements  of  walking  may  likewise 
be  accomplished  without  difficulty,  but  the  entire  act  of 
taking  steps  voluntarily  results  in  the  stammering  tendency 
to  which  allusion  has  been  made.  Explanation,  encourage- 
ment and  instruction,  on  the  other  hand,  quickly  produce 
results,  and  it  is  not  difficult  to  induce  such  patients  to 
walk  with  comparative  ease  through  the  use  of  such  simple 
means.  It  is,  therefore,  apparent  that  we  have  in  this  dis- 
turbance to  deal  with  a  mental  defect,  presumably  dependent 
upon  the  senile  changes  of  cerebral  vessels,  which  have,  how- 
ever, not  led  to  sufficient  injury  to  produce  marked  degenera- 
tion of  the  motor  tracts.  At  this  time,  when  the  general 
subject  of  arteriosclerosis  is  demanding  much  attention,  it  is 
worth  while  to  call  attention  to  this  trepidant  abasia  of  the 
aged  as  illustrative,  not  only  of  the  infirmities  which  the  vascu- 
lar lesions  themselves  produce,  but  also  as  demonstrating  the 
probable  secondary  effects  upon  the  mind,  which  in  turn 
lead  to  a  lack  of  confidence,  finally  resulting  in  a  practical 
incapacity  for  voluntary  walking  movements.  The  interest 
of  these  cases,  therefore,  lies  not  so  much  in  the  gait  disturb- 
ance itself  as  in  the  curious  chain  of  events  which  finally 
brings  it  to  pass.  Much  may,  no  doubt,  be  done  in  the  way 
of  treatment  by  perseverance,  both  on  the  part  of  patient 
and  physician,  in  retraining  the  motor  functions  through  an 
appeal  to  the  will. 


BRAIN. 


I8I 


Case  70.  T.,  a  man  of  forty-five,  about  August  i,  19 10, 
had  an  attack  the  exact  character  of  which  cannot  be  deter- 
mined. It  Is  supposed,  however,  that  it  was  of  gradual  onset 
with  temporary  paresis  of  the  right  hand  and  leg,  associated 
with  some  disturbance  of  vision  In  the  right  eye  and  a  very 
marked  difhculty  In  speech.  The  first  thing  he  himself  noticed 
was  that  he  was  unable  to  deliver  a  message.  A  month  later 
he  had  what  was  supposed  to  be  an  epileptic  attack.  Since 
then  he  had  had  three  or  four  similar  seizures.  In  one  of  which 
he  was  seen  while  sitting  In  his  chair  to  have  convulsive 
movements  of  the  hands  and  arms,  with  distortion  of  the  face, 
associated  with  apparent  unconsciousness  and  mucous  dis- 
charge from  the  mouth. 


Fig.  31.     Case  70.     Hemianopsia. 

When  examined,  on  November  25,  there  was  a  scarcely 
noticeable  weakness  of  the  right  foot  and  right  hand  and  an 
almost  complete  loss  of  the  power  of  speech.  His  vocabulary 
at  that  time  consisted  of  hardly  more  than  the  words  "  yes  " 
and  "  no."  The  knee  jerks  were  active;  the  pupils  reacted 
to  light  and  on  accommodation,  the  right  being  slightly  smaller 


l82  CASE   HISTORIES    IN    NEUROLOGY. 

than  the  left.  The  heart  was  regular  in  action,  slightly 
enlarged,  with  a  definite  musical  systolic  murmur  at  the  apex. 
The  urine  was  high  colored,  specific  gravity  1,015,  ^lo  sugar, 
a  large  trace  of  albumin,  with  sediment  consisting  of  occasional 
small  round  cells  and  leucocytes,  together  with  some  squamous 
and  epithelial  cells.  There  were  numerous  hyaline  and  granu- 
lar casts,  but  no  blood  or  fat.  He  improved  somewhat  and 
enlarged  his  vocabulary  to  a  slight  but  not  useful  degree. 
He  was  finally  admitted  to  a  hospital  for  chronic  disease, 
March  8,  191 1,  where  the  following  supplementary  examina- 
tion was  made:  Pupils  equal;  good  reaction  to  light  and  on 
accommodation,  with  normal  ocular  movements.  Vision 
restricted  to  the  left  half  of  the  field  (hemianopsia),  tongue 
protruded  in  the  median  line,  clean  and  moist;  teeth  in  fair 
condition,  throat  negative,  chest  symmetrical  and  without 
disease  of  the  lungs.  The  heart  apex  was  in  the  fifth  space, 
somewhat  enlarged  toward  the  left;  the  sounds  were  clear, 
the  first  accentuated  and  accompanied  by  a  questionable 
thrill.  With  the  second  sound  at  the  apex  was  heard  from  time 
to  time  a  squeak,  transmitted  downward  and  into  the  axilla. 
The  aortic  second  sound  was  not  greater  than  the  pulmonic 
second.  The  abdomen  showed  no  abnormality.  The  legs 
were  normal;  the  original  slight  paresis  had  disappeared. 
The  urine  also  showed  no  further  abnormality  than  a  high 
specific  gravity  with  an  alkaline  reaction, 

A  more  detailed  examination  of  the  aphasia  revealed  the 
following  conditions  as  examined  March  31,  1 9 1 1 .  The  tongue 
was  tremulous  but  freely  movable;  there  was  no  paralysis 
of  the  facial  muscles  nor  was  the  larynx  affected.  Right 
hemianopsia  was  easily  demonstrated.  Spontaneous  speech 
was  not  possible.  He  was  unable  to  repeat,  "  This  is  the 
Long  Island  Hospital,"  or  "  This  is  a  pleasant  day."  He 
named  objects  with  the  following  results:  Pencil  —  Eskimos; 
watch  —  correct;  chain  —  correct;  knife  —  unable  to  an- 
swer, but  when  the  word  was  mentioned  he  agreed  at  once; 
note  book  —  doesn't  know ;  keys  —  correct ;  one-cent  piece  — 
copper;  five-cent  piece  —  unable  to  answer;  twenty-five 
cent  piece  —  unable  to  answer.  He  was  unable  to  copy  and 
apparently  did  not  clearly  understand  what  he  was  asked 


BRAIN.  183 

to  do.  When  asked  to  write,  declined  on  the  ground  that  he 
could  not  see  (hemianopsia) ;  asked  how  old  he  was,  could  not 
answer.  ,  His  comprehension  was  very  defective.  When  asked 
to  touch  his  nose  with  his  forefinger,  he  failed  entirely  to 
understand.  When  asked  to  put  out  his  tongue,  opened  his 
mouth  instead,  and  thrust  out  his  tongue  when  told  to  close 
his  right  eye.  He  was  unable  to  touch  his  right  ear  at  com- 
mand; when  asked  to  pick  up  variously  shaped  pieces  of 
paper  he  mistook  a  small  piece  for  a  long  piece  several  times, 
but  some  of  the  commands  involving  thought  he  carried  out 
correctly,  which  showed  considerable  improvement. 

Diagnosis.  The  lesion  in  this  case  is  vascular  in  character, 
possibly  embolic  in  view  of  the  definite  heart  lesion.  The 
middle  cerebral  artery  is  undoubtedly  the  seat  of  the  difificulty, 
the  lesion  invading  to  a  very  slight  degree  the  internal  capsule 
and  extending  more  posteriorly  into  the  zone  of  sensory 
speech,  interrupting  also  the  optic  fibers  as  shown  by  the  pres- 
ence of  hemianopsia.  The  aphasia  is  of  a  mixed  type,  since 
he  not  only  understands  very  imperfectly  but  is  also  unable 
to  enunciate  words,  in  striking  contrast  to  the  condition 
described  in  Case  71.  The  element  of  paraphasia  is,  however, 
lacking  in  this  case.  In  spite  of  the  marked  motor  defect, 
it  seems  probable  that  Broca's  convolution  (third  left  frontal) 
is  not  invaded  by  the  pathological  process,  and  that  the  lesion 
lies  rather  in  the  lenticular  zone  and  posterior  to  that  region. 
The  association  of  a  marked  sensory  defect  with  hemianopsia 
bears  out  this  supposition. 

Prognosis.  The  patient  has  steadily  improved  since  the 
original  attack.  The  renal  disturbance  was  apparently  tran- 
sient, as  shown  by  the  later  urinary  examination,  and  the 
epileptiform  attacks  have  not  recurred.  The  aphasia  has 
improved  somewhat,  but  he  is  not  likely  to  regain  anything 
approaching  perfect  speech. 

Treatment.  Attention  should  be  given  to  the  heart, 
which  is,  as  yet,  well  compensated;  the  urine  should  be  ex- 
amined from  time  to  time  and  the  diet  regulated  in  view  of 
possible  kidney  complications.  The  aphasia  might  be 
improved  somewhat  through  training,  but  further  spon- 
taneous improvement  will  be  increasingly  slow. 


184  CASE   HISTORIES    IN    NEUROLOGY. 

Case  71.  O.,  a  widow  of  sixty-four,  during  a  period  of  two 
and  a  half  years  had  had  several  attacks  of  apparent  acute 
indigestion  characterized  by  sudden  vomiting,  with  a  slight 
rise  in  temperature.  These  attacks  lasted  about  one  week 
and  were  thought  to  be  traceable  to  overwork  or  indiscretion 
in  diet.  She  recovered  completely  from  each  of  them.  For 
six  months  preceding  the  time  when  she  was  examined  she 
had  been  increasingly  irritable  and  at  times  was  unable  to 
say  what  she  wished  to.  She  was  also  unable  to  play  cards 
as  well  as  formerly.  One  week  before  being  seen,  while  in  a 
condition  of  apparently  good  health,  she  had  an  attack  such 
as  those  described  above,  associated  with  headache  and  a 
marked  difficulty  in  understanding  what  was  said  to  her. 
The  fundus  was  said  to  be  normal.  A  consultant,  who  saw 
her  at  this  time,  found  her  thoracic  and  abdominal  organs 
normal  and  diagnosticated  a  brain  tumor. 

Examination.  The  first  impression  of  this  patient  was 
that  she  was  mentally  disordered  and  in  a  highly  excited 
state,  associated  with  much  confusion.  On  investigation, 
however,  it  was  forthwith  apparent  that  this  seeming  mental 
disturbance  was  due  solely  to  a  marked  speech  defect  from 
which  she  was  suffering.  She  continually  used  meaningless 
words,  which  to  her  mind  apparently  conveyed  a  definite 
idea.  She  also  confused  her  words  in  constructing  sentences. 
She  was,  however,  extremely  voluble  and  had  not  the  slightest 
difficulty  in  enunciating  or  finding  a  word,  although  it  was 
often  an  incorrect  one,  to  convey  the  meaning  she  desired. 
She  refused  to  name  objects  held  before  her  and  said  she 
couldn't.  It  was  also  doubtful  whether  she  understood  the 
use  of  objects  (apraxia).  The  misuse  of  words  was  striking; 
for  example,  her  physician  had  recently  shaved  his  moustache. 
Regarding  this,  she  said,  "  You  have  sawed  off  your  face." 
Again,  speaking  of  her  eye,  she  said,  "  I  have  done  a  lot  of 
work  with  that  dog."  Spontaneous  writing  was  imperfectly 
possible;  she  was  unable  to  copy.  The  alphabet  was  written 
as  follows:  a  b  s  d  f  e  ft  get  hav  i  ju  K  1  m  n  o  op,  etc. 
Given  a  dictation,  "  This  is  a  pleasant  day,"  wrote,  "  This  is  a 
dleasant."  Examination  .of  the  visual  fields  showed  a  left 
hemianopsia.     This  patient  greatly  improved  later,  recovered 


BRAIN.  185 

practically  normal  speech  and  became  essentially  as  well  as 
before  the, attack. 

Diagnosis.  It  is  altogether  probable  that  the  condition 
described  above  was  due  to  a  disturbance  in  the  circulation 
of  the  left  middle  cerebral  artery,  supplying  the  region  of 
the  island  of  Reil  and  presumably  the  upper  temporal  con- 
volution. The  Aphasia  resulting  fromt  his  lesion  was  of  the 
sensory  type,  characterized  by  an  incapacity  to  understand, 
associated  with  paraphasia  well  exemplified  in  this  case, 
together  with  the  subsidiary  defects  of  writing  and  copying. 
The  fact  that  she  had  no  difficulty  whatever  in  finding  words,  in- 
correct as  they  usually  were,  and  spoken  without  the  slightest 
hesitation,  indicates  that  the  more  anterior  portion  of  the  zone 
of  language  was  not  affected.  The  existence  of  hemianopsia 
goes  to  show  that  the  lesion  extended  posteriorly  to  a  point 
in  the  region  of  the  angular  gyius  with  an  interruption  of  the 
fibers  of  the  optic  radiation  of  the  left  side. 

Prognosis.  As  stated  in  the  history,  the  patient  recovered 
almost  completely  from  this  attack.  Others  are  likely  to 
follow,  probably  proving  more  serious. 

Treatment.  The  treatment  was  symptomatic.  In  such 
cases,  if  the  heart  action  is  weak  and  there  is  evidence  of  throm- 
bus formation  in  the  cerebral  vessels,  it  is  desirable  to  use 
stimulants,  of  which  strychnia  is,  perhaps,  the  best.  A  condi- 
tion such  as  that  described  in  this  case  is  more  likely  to 
result  from  this  cause  than  from  hemorrhage. 


1 86  CASE    HISTORIES    IN    NEUROLOGY. 

Case  72.  R.,  a  man  of  thirty-five,  otherwise  well,  and  active 
in  his  professional  work,  had  for  some  years  had  a  more  or 
less  acutely  suppurating  middle  ear  on  the  left  side.  This 
had  occasioned  him  no  great  inconvenience  until  finally 
he  had  had  considerable  pain  in  the  mastoid  region  and  came 
to  Boston  to  consult  an  aurist.  After  examination  it  was 
considered  probable  that  the  mastoid  cells  were  involved  in 
the  suppurati\'e  process  and  that  an  operation  for  its  relief 
was  demanded.  This  operation  was  done  under  great  diffi- 
culties owing  to  the  fact  that  the  anesthetic  was  very  badly 
taken;  the  patient  was  stout  and  the  mastoid  portion  of  the 
bone  was  extremely  small.  Nothing  definite  was  found  as 
a  result  of  this  operation.  The  patient,  who  had  previously 
shown  some  signs  of  cerebral  disturbance,  did  not  improve. 
He  had  a  slight  continued  temperature,  and  a  very  definite 
speech  defect  gradually  developed.  In  other  respects,  he 
was  not  at  that  time  seriously  ill.  He  was  able  to  be  about, 
dressed,  and  took  a  considerable  degree  of  interest  in  the  prog- 
ress of  his  condition. 

Examination  showed  that  he  had  no  hemianopsia.  His 
understanding  of  commands  was  imperfect,  he  misused  words, 
WTote  with  many  mistakes  and  made  himself  understood  with 
the  very  greatest  difficulty.  When  shown  objects  and  asked 
to  name  them  he  rarely  did  so  correctly.  A  list  follows: 
Ring — "ring."  Pen  —  "  wentum  nebo  ";  when  asked 
what  one  does  with  it,  said,  "  You  write  with  it."  Fan  — 
"  book  of  ridal  surgents.  It's  ridal  surgents.  I  mean  by 
that  a  book  which  has  its  name  on  surgery.  Fan  stands 
for  fan.  Is  that  a  fan?  Probably  yes."  Handkerchief  — 
"  shauma  —  lamp,  looks  a  good  deal  like  a  lantern."  Necktie 
—  "I  call  that  a  regular  iron  wing."  Keys  —  "  trees,  but  I 
don't  know  which  ones."  Flies —  "  birds."  Automobile,  when 
seen  in  a  picture  —  "epileptic  something."  Spontaneous 
speech:  "  Now,  why  Is  it  that  a  fellow  can  say,  well,  now 
suppose,  like  a  cane  fellow,  why  is  it  he  says  too  much,  too 
little,  why  is  it  such  fellow  is  revaiste,  why  is  it  that  I  have 
to  look  around  at  this  and  that  and  that  sort  of  business, 
I  don't  believe  it  can  be  fixed  right  away."  He  was  entirely 
unable  to  read;    he  used  words  of  slightly  the  same  sound 


BRAIN.  187 

but  wholly  unmeaning.  Some  words  were  pronounced,  but 
evidently  he  did  not  understand  what  he  read.  He  spelled 
with  great  difficulty.  When  a  question  was  written,  he  under- 
stood it.  When  asked  to  copy,  he  did  not  clearly  realize 
what  was  meant.  When  asked  to  write  "  This  is  a  very 
warm  day,"  began  "  Dear  sir,  please  send  me  a  sider." 
When  asked  to  state  how  he  felt,  wrote,  "  I  don't  feel,  I  feel 

very ."      These  difficulties  increased  so  that  his  speech 

became  practically  unintelligible.  Vertigo  developed  and  his 
general  condition  grew  decidedly  worse.  Operation  was  un- 
wisely deferred,  largely  because  it  was  felt  after  the  previous 
experience  that  he  could  not  survive  the  necessary  explora- 
tion. After  reaching  a  somewhat  alarming  condition,  sud- 
denly one  night  there  was  a  gush  of  pus  from  the  left  ear 
with  an  immediate  improvement  in  all  symptoms  and  a 
complete  restoration  of  speech.  The  following  day  the 
patient  wrote  an  absolutely  perfect  statement  in  a  clear, 
bold  hand  with  no  mistakes  either  in  spelling,  punctuation 
or  phraseology.  He  spoke  equally  well.  The  ear  continued 
to  discharge  a  greenish  pus  for  a  week  or  ten  days  and  then 
spontaneously  ceased.  The  patient  to  all  appearances  was 
entirely  well.  He  spent  a  comfortable  and  enjoyable  summer 
but  was  admitted  to  a  hospital  in  the  fall  with  similar  symp- 
toms to  those  already  described.  Operation  undertaken  at 
that  time  resulted  In  death  on  the  table.  The  exposure 
of  the  left  temporal  lobe  revealed  a  large  abscess  cavity 
filled  with  pus,  which  the  later  autopsy  showed  had  disinte- 
grated a  considerable  part  of  the  temporal  lobe. 

Diagnosis.  Cerebral  Abscess  was  probable  as  soon  as  symp- 
toms on  the  part  of  the  brain  manifested  themselves.  It 
was  rendered  almost  certain  by  the  development  of  an 
Aphasia  of  the  sensory  type.  The  discharge  of  pus  from  the 
ear  absolutely  established  the  diagnosis.  The  aphasia  was 
characterized,  as  indicated  in  the  history,  by  faulty  under- 
standing (word  deafness),  Incapacity  to  express  himself  on 
account  of  the  misuse  of  words,  with  retained  capacity  to 
speak.  The  lesion  causing  this  disturbance  lay  in  the  tem- 
poral lobe  and  did  not  invade  the  lenticular  zone,  although, 
undoubtedly,  certain  of  the  conduction  fibers  from  the  tem- 


1 88  CASE   HISTORIES    IN    NEUROLOGY. 

poral  lobe  were  destroyed.  The  lesion  did  not  reach  the  optic 
fibers,  as  shown  by  the  absence  of  hemianopsia. 

Prognosis.  Untreated  cerebral  abscess  is  finally  fatal  in 
the  great  majority  of  cases.  It  is,  however,  possible  that  such 
lesions  may.  occasionally  remain  latent  for  long  periods  with 
ultimate  obliteration  of  the  cavity. 

Treatment.  The  treatment  of  cerebral  abscess  is  surgical. 
It  was,  as  the  event  proved,  a  false  hope  to  suppose  that 
a  spontaneous  evacuation  of  pus  through  the  ear  would  re- 
sult in  cure.  A  slow  refilling  of  the  cavity  led  directly  to  the 
final  fatal  outcome.  There  was  no  reinfection,  but  the  bacteria 
(B.  pyocyaneus)  were  sufficiently  active  to  lead  to  a  reforma- 
tion of  pus. 


BRAIN.  189 

Case  73.  I.,  a  man  of  thirty-three,  was  seen  October  22, 
1906.  He  was  unmarried  and  an  engineer  by  occupation. 
Seven  weeks  before,  he  had  had  an  acute  suppuration  of  the 
right  ear,  preceded  by  pain.  No  operation  or  interference 
was  attempted  at  a  hospital  to  which  he  went  for  treatment. 
He  was  thereafter  able  to  do  some  work,  but  with  diminished 
capacity.  For  the  preceding  four  weeks,  however,  he  had 
remained  at  home  with  varying  feelings  of  discomfort, 
chiefly  of  pain,  which  was  practically  constant  on  the  right 
side  of  the  head,  radiating  through  the  eye  of  that  side  and 
through  the  vertex  and  occiput.  For  three  days  he  had  been 
decidedly  worse;  his  appetite  failed;  he  was  dull  mentally 
and  took  to  his  bed.  Vertigo  supervened  and  he  failed  to 
recognize  a  close  relative.  His  mind,  in  general,  was  wander- 
ing and  uncertain,  showing  considerable  confusion. 

Examination  showed  the  following  conditions :  The  patient 
lay  with  his  eyes  closed,  extremely  apathetic  but  not  asleep. 
It  was  possible  to  rouse  him  to  answer  questions  In  connection 
with  the  examination.  The  pupils  were  unequal,  the  right 
larger  than  the  left,  with  a  delayed  light  reflex ;  there  was  slight 
palsy  of  the  left  facial  nerve;  whistling  was  difficult;  the 
sensation  of  the  face  was  normal  and  the  motor  portion 
of  the  fifth  nerve  was  not  involved.  There  was  no  diplopia 
in  spite  of  the  fact  that  there  was  an  apparent  slight  external 
strabismus  due  to  the  Imperfect  action  of  branches  of  the 
third  nerve  (it  is  probable  that  his  mental  state  precluded  the 
recognition  of  double  images).  There  was  some  Indication 
of  the  Cheyne-Stokes  type  of  respiration.  The  arm  reflexes 
were  active  and  normal  and  the  muscular  strength  was  equal 
on  the  two  sides.  The  legs  also  showed  equal  strength,  with 
active  knee  reflexes,  no  clonus,  normal  plantar  and  Achilles 
response.  So  far  as  it  was  possible  to  determine,  the  sensation 
of  the  legs  was  normal.  On  attempting  to  walk,  the  gait  was 
very  uncertain;  there  was  complaint  of  vertigo  and  of 
tinnitus  In  the  right  ear.  A  watch  was  heard  at  six  inches  on 
the  left,  but  there  was  no  air  conduction  on  the  right;  there 
was  slight  bogglness  behind  the  right  ear.  The  heart  sounds 
were  normal;  the  pulse  from  44  to  48  and  regular  In  time. 
The  temperature  at  the  examination  was  98.6°. 


I90  CASE   HISTORIES    IN    NEUROLOGY. 

A  diagnosis  of  cerebral  abscess  was  made,  presumably  of 
the  right  temporal  lobe,  and  operation  was  advised  and 
accepted  at  once.  The  mastoid  was  trephined  and  no  pus 
found.  A  secondary^  opening  above  the  mastoid  showed  at 
once  a  bulging  brain,  evidently  under  much  pressure.  The 
opening  was  enlarged  and  a  slight  opacity  of  the  pia  showed 
the  probable  site  of  the  lesion ;  a  probe  was  passed  downward 
and  forward  with  the  immediate  effect  that  a  gush  of  yellow 
pus  flowed  out.  The  opening  was  enlarged,  with  the  result 
that  more  pus  was  obtained.  The  pulse  was  44  before  the 
operation,  120  to  158  during,  and  60  after  the  operation. 
The  recovery  from  ether  was  entirely  satisfactory  and  the 
patient  was  left  with  provision  for  free  drainage.  At  the  end 
of  two  days  there  had  been  no  temperature;  the  pulse  was  60; 
no  paralysis  had  developed;  the  pupils  were  equal  in  size. 
He  was  able  to  sit  up  for  the  dressing  and  his  only  complaint 
was  a  severe  backache.  The  following  day,  however,  he  grew 
decidedly  worse  and  died  twenty-four  hours  later. 

Diagnosis.  In  the  presence  of  an  active  suppurating  ear 
with  subsequent  development  of  cerebral  symptoms  of  the 
nature  of  dullness  and  disturbance  in  the  cranial  nerve 
innerv^ation,  it  is  safe  to  make  a  probable  diagnosis  of  Cerebral 
Abscess  from  extension  of  suppuration  through  the  thin  bone 
into  the  temporal  lobe,  or  less  frequently  into  the  cerebellum. 
The  slow  pulse  in  this  case  was  indicative  of  increased  pres- 
sure, although  this  is  by  no  means  a  constant  sign.  Unfor- 
tunately no  ophthalmoscopic  examination  was  made.  A 
normal  temperature  should  not  militate  against  a  diagnosis 
of  a  local  suppurative  process.  In  abscess  of  the  brain  the 
temperature  is  often  subnormal  as  well  as  elevated.  It  is, 
however,  neither  constant  in  its  type  nor  in  any  way  char- 
acteristic. If  the  lesion,  as  in  this  case,  is  on  the  right  side, 
it  is  often  difficult  to  determine  between  a  temporal  and  a 
cerebellar  localization.  If  on  the  left  side,  in  right-handed 
persons,  the  appearance  of  a  sensory  aphasia  is  a  most  im- 
portant diagnostic  sign  of  invasion  of  the  temporal  lobe 
(Case    72). 

Prognosis.  In  this  case,  death  presumably  resulted  from 
an  extension  of  the  infection  to  the  meninges,  a  constant  dan- 


BRAIN.  191 

ger  in  operations  for  abscess.  In  general,  if  the  abscess  is 
sufficiently  walled  off  and  drainage  is  adequate,  cure  may  be 
expected  in  a  certain  proportion  of  the  cases.  It  is  no  doubt 
desirable  to  extirpate  the  sac  for  the  purpose  of  preventing 
the  refilling  of  the  abscess,  with  ultimate  fatal  outcome,  as 
shown  in  Case  72.  A  complication  in  the  prognosis  is  the 
coexistence  of  a  lateral  sinus  thrombosis. 

Treatment.  Although  it  is  no  doubt  possible  for  cerebral 
abscess  to  remain  walled  off  and  latent  for  many  years,  with 
a  possible  final  spontaneous  cure,  this  fact  should  not  justify 
conservatism  in  drainage,  particularly  in  cases  of  acute 
onset.  The  treatment  is  essentially  surgical,  the  object  being 
to  expose,  drain,  and  if  possible  to  destroy  the  pyogenic 
membrane.  If  the  diagnosis  of  the  location  is  not  definite, 
it  is  desirable  first  to  expose  the  mastoid  cells  with  or  without 
tying  the  jugular  veins,  then  to  trephine  over  the  temporal 
lobe  and  finally  to  expose  the  cerebellum. 


192  CASE   HISTORIES    IN    NEUROLOGY. 

Case  74.  E.,  a  woman  of  forty,  unmarried,  had  had  consid- 
erable headache,  especially  at  night,  for  a  period  of  about 
eight  months.  She  had  also  had  some  \'ertigo  for  a  part  of 
this  time,  but  in  spite  of  her  ill  feelings  had  gained  in  weight. 
She  had  lived  a  life  of  considerable  nervous  strain;  as  a  child 
she  was  not  strong  and  at  one  time  is  said  to  have  had  a 
"  ner\'ous  breakdown."  Three  weeks  before  being  seen,  she 
experienced  a  sudden  severe  pain  in  her  head,  with  immedi- 
ate disturbance  of  vision,  which,  however,  quickly  returned. 
She  was  able  to  be  about  on  the  following  day,  but  the  next 
night  was  unable  to  sleep  on  account  of  pain  at  the  back  of 
her  neck,  on  the  right  side  of  her  neck  and  in  her  head. 
The  following  days  her  head  remained  uncomfortable,  and 
stiffness,  associated  with  pain  of  the  muscles  of  the  right  side 
of  the  neck,  developed.  Following  this  her  neck  became 
swollen  on  the  right  side  and  she  had  extreme  tinnitus  in 
her  right  ear.  She  had  previously  had  some  ear  suppuration, 
but  no  disabling  disorder.  About  eight  days  after  the  onset 
she  vomited  several  times  and  had  a  constant  sense  of  nausea. 
The  head  pain  grew  worse  and  paroxysmal  in  character. 
She  described  her  sensation  as  if  her  "  head  was  filled  with 
blood."  This  pain  was  associated  with  defective  vision. 
The  vomiting  was  of  transient  duration  and  for  several  days 
had  given  her  no  discomfort.  She  noticed,  however,  that 
she  did  not  avoid  objects  properly  and  that  her  eyesight  was 
very  defective,  reaching  such  a  degree  that  she  was  unable 
to  count  fingers  two  feet  before  her  eyes.  An  ophthalmoscopic 
examination  showed  edema  and  hemorrhage  of  the  retinae, 
more  marked  on  the  right  than  on  the  left.  There  was  also 
slight  protrusion  of  the  eyes.  The  choking  of  the  disks 
increased,  with  corresponding  reduction  of  vision.  There  was 
absolutely  no  significant  temperature  at  any  time;  the  pulse 
varied  from  65  to  80  or  90;  the  urine  showed  a  faint  trace  of 
albumin  and  occasional  hyaline  casts. 

When  examined,  about  two  weeks  after  the  acute  onset, 
the  patient  was  difficult  to  arouse  but  perfectly  conscious. 
She  was  a  stout  woman,  lying  on  the  right  side  in  a  bent  posi- 
tion. The  eyeballs  were  prominent,  the  left  more  so  than  the 
right.     The  pupils  were  equal,  with  imperfect  light  response. 


BRAIN.  193 

There  appeared  to  be  some  difficulty  in  movement  of  the  bulbs, 
especially  of  the  left  eye,  outward.  She  was  practically 
blind,  with  excessive  choking  of  both  disks.  The  cranial  nerves 
were  otherwise  free  from  involvement.  There  was  no  definite 
swelling  in  the  neck  over  the  jugular  region;  the  pulse  was 
normal ;  there  was  no  paralysis  of  arms  or  legs.  The  patient 
appeared  to  be  growing  worse  and  was  evidently  suffering 
much  discomfort.  The  temperature  was  essentially  normal, 
the  oscillation  being  a  degree  or  part  of  a  degree  above  and 
below  the  normal  line.  The  subsequent  history  was  recovery, 
with  total  blindness. 

Diagnosis.  This  case  is  best  explained  on  the  theory  of  a 
non-infectious  Sinus  Thrombosis.  The  pain,  vertigo,  swelling 
of  the  jugular  region  of  the  neck,  with  subsequent  slight  pro- 
trusion of  the  eyeballs  and  rapidly  advancing  choked  disk, 
constitute  a  combination  of  symptoms  compatible  with  a 
filling  of  the  lateral  sinus  with  subsequent  extension  into 
the  cavernous  sinus.  The  paresis  of  ocular  muscles  finds  its 
explanation  in  the  passage  of  the  nerves  through  the  sinus. 
The  very  rapid  loss  of  sight  consequent  upon  a  choked 
disk  bears  out  the  theory  of  local  pressure  and  serves  also 
as  further  evidence  that  the  essential  cause  of  choked  disk 
is  pressure  behind  the  orbit.  Although  temperature  and  defi- 
nite signs  of  infection  usually  accompany  thrombosis  of  the 
cerebral  sinuses,  it  is  possible  that  such  a  thrombosis  may  run 
its  course  without  signs  of  infection,  as  in  this  case. 

Prognosis.  The  prognosis  of  sinus  thrombosis  is  always 
grave  but  not  necessarily  fatal,  even  if  untreated  surgically, 
as  shown  by  this  case. 

Treatment.  If  there  is  manifest  invasion  of  the  lateral 
sinus  the  jugular  vein  should  be  tied  to  prevent  a  further 
dissemination  of  the  process  through  emboli.  In  this  case, 
operation  was  not  indicated,  inasmuch  as  there  was  evidence 
that  the  lateral  sinus  was  free  from  clot.  The  outcome  justi- 
fied conservative  treatment,  since  the  recovery  was  progressive 
and  complete  with  the  exception  of  atrophy  of  the  optic 
nerves,  which  presumably  could  not  have  been  prevented 
at  any  stage  of  the  illness. 


194  CASE   HISTORIES    IN    NEUROLOGY. 

Case  75.  S.,  a  boy  of  five,  who  had  three  healthy  brothers 
and  sisters,  had  been  defective  from  birth.  His  mother 
had  had  no  miscarriages  and  the  labor  in  his  case  was  an 
easy  one.  His  head  was  from  the  first  small  and  his  arms 
and  legs  not  freely  movable.  At  eight  months,  he  had 
a  convulsion  which  was  followed  thereafter  at  varying 
inter\'als  by  others.  At  two,  his  legs,  which  had  previously 
been  becoming  spastic,  became  more  definitely  contractured 
and  finally  became  crossed  under  conditions  of  extreme 
rigidity.  His  mental  condition  was  evidently  defective  and, 
because  of  spasticity  and  contractures  both  of  the  arms  and 
of  the  legs,  he  was  practically  helpless. 

Examination  showed  a  very  poorly  developed  child  lying 
on  his  back,  moving  his  head  aimlessly  from  side  to  side  and 
occasionally  bending  his  back  and  retracting  his  head  in  a  semi- 
voluntary  manner.  Facial  movements  were  associated  with 
this.  The  head  was  small,  the  hair  fine  and  growing  low  down 
on  the  forehead.  The  ears  were  too  large,  the  eyes  expression- 
less, with  a  tendency  to  conjugate  deviation  and  nystagmus. 
The  pupils  were  equal  in  size  and  reacted  to  light.  There  was 
a  slight  degree  of  internal  strabismus.  The  mouth  was  open 
and  saliva  w^as  constantly  escaping.  The  palate  was  high 
and  the  teeth  very  defective.  Examination  of  the  body  organs 
showed  nothing  abnormal.  The  general  nutrition  was, 
however,  extremely  defective;  the  patient  was  very  thin, 
with  contracted  abdomen.  The  arms  were  rigid,  held  closely 
to  the  body,  flexed  at  the  elbow  and  somewhat  at  the  wrists, 
but  varying  decidedly  on  the  two  sides.  The  reflexes  could 
not  be  satisfactorily  tested  on  account  of  the  contractures. 
The  legs  were  crossed  at  the  thighs  and  were  both  extremely 
spastic,  contractured  and  wasted  from  lack  of  nutrition  and 
disuse.  The  toes  were  in  a  position  of  plantar  flexion  and,  as 
in  the  arms,  were  capable  of  very  slight  movements.  The 
knee  jerks  were  about  normal,  no  plantar  reflex  was  obtained, 
either  of  the  flexor  or  extensor  type,  and  no  clonus.  The  skin, 
both  of  arms  and  legs,  was  blue  and  glossy.  The  mental 
condition  of  the  child  was  evidently  most  defective.  He  never 
spoke,  paid  little  attention  to  what  was  going  on  about 
him,  but  was  capable  of  fixing  his  attention  momentarily  on 


BRAIN. 


195 


objects  if  directly  presented  to  him.  He  was  fed  with  diffi- 
culty and  swallowed  only  when  food  was  actually  forced  upon 
him.  Under  these  conditions  he  lingered  for  several  months 
and  finally  died  of  general  inanition. 

Autopsy.  The  post-mortem  examination  revealed  a  very 
defective  brain,  as  shown  in  the  accompanying  sketch.  The 
convolutions  were  small,  abnormally  placed  and  in  the  occipi- 
tal lobe  of  the  right  hemisphere  was  a  large,  porencephalic 
defect  connecting  the  surface  with  the  posterior  horn  of  the 
lateral  ventricle.  In  general,  the  brain  showed  deficient 
development  in  all  its  parts,  the  hemispheres  being  particu- 
larly small  and  not  covering  the  cerebellum.  There  were 
secondary  degenerations  in  the  motor  tracts.     The  skull  was 


Fig.  32.     Case  75.     Defective  Brain  ;  Porencephaly. 

deformed,  corresponding  to  the  defective  brain.  The  pleural 
cavity  on  the  left  was  almost  entirely  obliterated  by  old 
fibrous  adhesions ;  on  the  right,  collapsed  lung  lay  against  the 
wall,  with  various  adhesions.  The  lungs  were  infiltrated  by 
tuberculosis. 

Diagnosis.  It  was  evident  during  life  that  the  patient  was 
defectively  developed,  particularly  in  relation  to  the  nervous 
system,  and  also  that  the  condition  of  the  extremities  was  due 
to  definite  brain  lesion.  This  condition  is  known  as  Little's 
disease  or  Cerebral  Paralysis  of  children.  It  is  characterized, 
as  in  this  case,  by  spasticity  of  high  degree,  with  contractures 
often  leading  to  crossing  of  the  legs  and  great  difficulty  in 
locomotion.  The  reason  for  this  condition  lies  in  the  faulty 
development  or  destruction  of  the  motor  neurones  of  the  upper 
type.    The  condition  is  often  associated  with  feeble-minded- 


196  CASE   HISTORIES    IN    NEUROLOGY. 

ness  and  no  definite  pathological  anatomy  can  be  laid  down 
beyond  that  of  general  hypoplasia  with  or  without  actual 
porencephalic  defect.  The  condition  is  not  to  be  mistaken 
for  any  other  type  of  cerebral  disorder.  It  is  usually  congeni- 
tal and  of  obscure  etiology. 

Prognosis.  In  general,  the  life  of  persons  afflicted  with 
cerebral  paralysis  is  curtailed.  This,  however,  depends 
wholly  upon  the  extent  of  the  original  damage  or  failure  of 
development.  Therefore,  each  case  must  be  determined 
on  its  merits.  The  resistance  of  this  patient  was  extremely 
low  and  he  fell  a  ready  victim  to  tuberculosis,  although  during 
the  latter  part  of  his  life  under  most  excellent  hygienic  con- 
ditions. 

Treatment.  Treatment  is  essentially  unavailing  except 
through  the  palliation  or  correction  of  deformities  by  surgical 
means  and  on  the  medical  side  by  special  teaching  adapted 
to  the  degree  of  existing  intelligence. 


BRAIN.  197 

Case  76.  N.,  a  girl  of  five,  was  seen  In  December,  1906. 
Before  the  present  illness,  she  had  been  regarded,  in  general, 
as  a  normal  child  of  a  somewhat  nervous  temperament. 
Ten  days  before  being  seen,  she  had  had  an  unexplained 
attack  of  vomiting  which  had  continued  for  a  week ;  at  times 
this  vomiting  was  apparently  of  the  cerebral  type.  She  had 
no  fever  of  consequence,  and  no  apprehension  was  entertained 
regarding  her  condition.  Three  days  before  being  seen, 
she  was  found  on  the  floor,  having  fallen  while  attempting 
to  get  out  of  bed.  Spasmodic  movements  of  the  left  arm  were 
noticed  and  a  few  hours  later  a  paralysis  of  the  whole  left 
side  developed,  with  slight  involvement  of  the  face.  Since  this 
attack,  she  had  been  stuporous,  but  at  times  could  be  roused. 
Examination  of  the  internal  organs  showed  nothing  abnormal. 
A  lumbar  puncture  revealed  clear  fluid.  The  temperature 
had  risen  and  at  one  time  had  reached  106°,  falling  later  to 
102°  or  103°.  At  the  height  of  the  temperature  the  pulse  was 
200. 

Physical  examination  ten  days  after  the  onset  of  vomiting 
showed  a  temperature  of  102°,  pulse  between  100  and  120, 
paralysis  of  the  right  arm  and  leg  with  marked  contracture 
of  the  arm,  the  leg  being  held  straight  with  foot  inverted. 
The  knee  jerks  were  active,  the  right  greater  than  the  left; 
there  was  no  Babinski  sign  and  no  ankle  clonus.  The  Achilles 
reflex  was  more  active  on  the  unaffected  side,  doubtless  due  to 
the  contracture  on  the  paralyzed  side.  The  abdominal  reflex 
was  slightly  present  on  the  right;  not  obtained  on  the  left. 
The  pupils  were  widely  dilated,  responsive  to  light,  and  showed 
a  conjugate  deviation  toward  the  right.  The  head  also  was 
held  toward  the  right,  but  the  neck  was  not  markedly  rigid 
and  on  forced  movement  did  not  excite  pain.  There  was  no 
Kemig  sign.  The  child  was  slightly  conscious  and  played  with 
a  watch  chain,  but  refused  entirely  to  obey  commands,  as, 
for  example,  a  request  to  show  her  tongue.  There  was  slight 
twitching  on  the  right  side  of  the  face  and  in  the  right  arm. 
There  was  no  sign  of  injury  to  the  head  as  might  possibly 
have  been  expected  as  a  result  of  her  fall  from  the  bed. 

Four  and  a  half  months  later  she  was  seen  again  and  the 
following  history  was  given :   Six  weeks  before  she  had  become 


198  CASE   HISTORIES    IN    NEUROLOGY. 

nervous,  was  nauseated  and  continually  said,  "  I  am  going 
to  throw  up."  There  was  a  slight  temperature  for  eight  days, 
but  from  this  she  recovered,  excepting  that  there  were  some- 
what more  marked  convulsive  movements  of  the  face  and 
arms.  Previous  to  this  there  had  also  been  a  period  of  elevated 
temperature,  with  some  coryza,  associated  with  digestive 
disturbance,  and  about  four  weeks  previous  to  the  first  of  May 
she  had  had  a  period  of  apparent  fright,  with  heart  palpitation. 
She  appeared  dazed  and  was  apparently  unable  to  answer 
questions,  although  she  appeared  to  know  what  was  said  to 
her.  She  complained  of  sore  throat,  although  examination 
showed  none.  These  attacks  had  been  repeating  themselves 
nightly  before  going  to  bed ;  they  were  quickly  over  and  she 
was  perfectly  calm  afterwards.  She  had  had  similar  attacks 
in  her  sleep,  when  she  stood  up  in  bed  much  frightened,  with 
twitching  of  the  left  side.  On  the  whole  these  attacks  had  in- 
creased in  frequency,  at  times  reaching  as  many  as  twelve 
in  twenty-four  hours.  She  became  increasingly  restless,  sleep 
was  disturbed,  and  there  was  some  urinary  incontinence,  with 
occasional  complaint  of  headache. 

Vomiting  did  not  persist.  The  twitching  movements 
always  began  in  the  left  arm.  Examination  at  this  time 
showed  equal  pupils  with  good  light  reaction,  no  strabismus 
or  deviation.  There  was  a  slight  left  facial  palsy,  together 
with  slight  paralysis  of  the  left  hand,  arm  and  leg  and  athe- 
toid  movements  of  the  left  hand.  The  gait  was  normal  except 
for  a  very  slight  limp.  The  knee  jerks  were  active;  no  clonus 
or  Babinski  could  be  elicited.  The  patient  was  very  restless 
during  the  examination,  had  a  marked  speech  defect  and 
showed  defect  in  intelligence.  Her  curiosity  was,  however, 
easily  aroused.  In  general,  she  had  improved  physically, 
but  her  mental  state  had  shown  no  such  definite  tendency. 
At  times  she  was  destructive;  she  was  always  happy,  never 
cried,  enjoyed  her  food  and  was  in  constant  motion. 

Diagnosis.  The  diagnosis  of  this  case  presents  certain 
difficulties.  Tuberculous  meningitis  may  be  excluded  because 
of  her  relative  recovery.  Meningitis  of  other  types  is  unlikely 
because  of  the  lack  of  neck  rigidity  and  a  clear  spinal  fluid. 
Furthermore,  the  predominant  involvement   of   the   cortex, 


BRAIN.  199 

although-  by  no  means  unknown  In  acute  meningitis,  is  unu- 
sual. A  more  likely  supposition  is  that  the  patient  suffered 
an  attack  of  Encephalitis  localized  essentially  in  the  right 
motor  area.  The  primary  spasmodic  movements  of  the  left 
hand  followed  by  a  hemiplegia  lends  weight  to  this  supposition. 
It  should  be  remembered  that  hemiplegia  in  children  is 
usually  caused  by  cortical,  rather  than  by  capsular,  lesions. 
The  secondary  epileptiform  attacks  are  consistent  with  this 
diagnosis.  The  analogy  of  this  lesion  to  poliomyelitis  is 
striking;  it  is,  in  fact,  altogether  possible  that  the  conditions 
are  identical,  differing  only  in  the  localization  of  the  patho- 
logical process. 

Prognosis.  The  prognosis  for  life  in  this  case  is  good,  but 
it  is  probable  that  the  patient  will  not  develop  normally 
on  the  mental  side,  will  retain  some  physical  defects  and  may 
be  epileptic. 

Treatment.  Bromides  proved  useful  in  quieting  the  ex- 
citement. Sodium  salts  should  be  given  in  doses  of  5  grains, 
repeated  several  times  a  day  as  needed.  Much  importance 
is  to  be  attached  to  the  general  care  and  education  of  such  a 
defective  child  in  the  future.  She  should  not  be  allowed  to 
go  to  the  public  schools  except  as  she  may  be  enrolled  in  a 
special  class. 


200  CASE   HISTORIES    IN    NEUROLOGY. 

Case  77.  E.,  an  unmarried  woman  of  twenty-four,  employed 
in  a  mill,  was  first  seen  November  29,  1910,  She  gave  the 
following  history.  There  was  nothing  of  significance  in  her 
family  history;  she  had  had  children's  diseases  and  four  years 
ago  had  been  operated  upon  for  c}'stic  o\'ary  and  prolapse 
of  the  uterus.  This  condition  had  given  her  no  further  trouble. 
Seven  weeks  before  being  seen,  she  began  to  notice  that  ob- 
jects seemed  blurred.  A  week  later  she  had  a  sudden  severe 
headache,  localized  chiefly  over  the  top  of  the  head.  She 
gave  up  work  and  went  to  bed,  the  headache  continuing  and 
extending  into  the  back  of  her  head  and  neck.  The  neck 
became  stiff  so  that  she  was  unable  to  move  her  head  to  any 
degree  for  two  weeks.  During  this  attack  she  vomited  two 
or  three  times  a  day.  About  four  weeks  before  being  seen, 
she  again  had  distinct  blurring  of  vision,  and  considerable 
tinnitus  had  developed. 

An  examination  on  December  7  gave  the  following  results: 
There  was  no  disturbance  of  smell.  Vision  was  markedly 
blurred  and  there  was  sharp  pain  through  both  eyes;  the 
pupils  reacted  to  light  but  not  to  distance.  There  was  no  hemi- 
anopsia, but  a  reduction  of  the  visual  field  in  the  left  eye 
was  apparent,  which  at  that  time  appeared  normal  in  the  right. 
There  was  choking  to  the  degree  of  several  diopters  of  both 
disks,  the  left  more  marked  than  the  right.  The  vessels  were 
tortuous,  the  outlines  of  the  disks  gone,  and  many  small 
hemorrhages.  There  was  palsy  of  the  left  external  rectus 
and  the  right  internal  rectus  with  retained  slight  action  of 
the  left  internal  rectus  and  the  right  external  rectus.  There 
was  no  ptosis  and  she  was  able  to  close  her  eyes  tightly. 
The  fifth  and  seventh  nerves  showed  no  abnormality.  Hear- 
ing of  w^atch  tick  was  possible  at  one  foot  in  both  ears.  Bone 
conduction  by  tuning  fork  was  heard  for  sixteen  seconds  on 
the  left  and  for  twelve  seconds  on  the  right.  The  ninth, 
tenth,  eleventh  and  twelfth  nerves  were  normal.  There  was 
no  ataxia  of  the  hands;  hand  grasp  was  equal  on  the  two 
sides  and  the  general  muscular  tonicity  of  the  arms  equal. 
There  was  no  astereognosis.  The  knee  jerks  were  obtained 
only  on  reinforcement,  the  right  more  active  than  the  left. 
No  Achilles,  Babinski,  Oppenheim  or  ankle  clonus  was  present. 


BRAIN. 


201 


There  was  no  Romberg  sign.  The  heart,  lungs,  abdomen  and 
urine  showed  nothing  abnormal.  The  gait  was  extremely 
uncertain,  partly,  no  doubt,  due  to  defective  vision. 

Intracranial  pressure,  presumably  due  to  tumor,  was  diag- 
nosticated and  the  patient  was  admitted  to  a  hospital  early 
in  December  for  operation.  A  right  subtemporal  decompres- 
sion was  done  December  14,  under  ether  anesthesia.  The 
dura  bulged  through  the  opening,  and,  when  nicked,  a  jet  of 
cerebrospinal  fluid,  under  pressure  sufficient  to  throw  it  twenty 
centimeters  in  height,  escaped.  Attempts  to  puncture  the 
ventricle  failed.  The  wound  was  closed  without  drainage, 
and  an  excellent  operative  recovery  followed.  Vision  im- 
proved very  quickly,  but  diplopia  remained.  On  December 
24,  the  disks  were  fairly  well  defined  and  the  swelling  had 
largely  subsided.  A  week  later,  the  hernia  of  the  brain  had 
increased  in  size  and  vision  was  greatly  improved  although 
far  from  normal.  She  was  able  to  distinguish  colors  and  could 
read  to  a  certain  extent.  The  right  eye  showed  a  third 
vision  and  the  left  a  sixth.  Both  disks  were  plainly  visible, 
there  was  no  swelling,  but  signs  of  beginning  atrophy  were 
appearing.  Two  weeks  later  a  cyst  had  formed  over  the  site 
of  operation,  which  was  tapped,  yielding  about  three  ounces 
of    clear,  straw-colored  fluid,  non-infected.     Since  improve- 


FiG.  33.    Case  77.    Visual  Fields,  February  6. 


202  CASE   HISTORIES    IN    NEUROLOGY. 

mcnt  had  ceased,  a  similar  decompression  operation  to  the 
first  was  done  on  the  left  side.  The  dura  was  less  tense 
than  at  the  first  operation,  but  there  was  some  bulging. 
As  before,  no  tumor  was  found.  The  dura  was  replaced  and 
the  wound  closed.  She  recovered  well  from  the  operation, 
but  her  eyesight  did  not  again  impro\'e.  On  February  23, 
somewhat  over  two  months  after  the  first  operation,  the  state- 
ment was  made  that  she  had  some  headache,  but  had  only 
had  one  severe  attack  in  the  preceding  two  weeks.  She  had  had 
no  nausea,  vomiting  or  vertigo,  and  her  appetite  was  good. 
She  could  not  see  well  enough  to  read.  She  had,  in  general, 
been  very  much  more  confortable  since  the  operations,  with 
practical  cessation  of  all  symptoms  and  marked  temporary 
improvement  in  sight.  No  further  operation  appeared 
justified. 

Diagnosis.  Headache,  vomiting,  choked  disk  and  vertigo 
are  sufficient  always  to  determine  the  presence  of  increased 
intracranial  pressure.  In  this  case,  these  symptoms  were 
well  marked  when  she  was  first  examined,  leaving  small 
doubt  that  she  was  suffering  from  a  Brain  Tumor,  which  is, 
by  all  means,  the  most  common  cause  of  cerebral  pressure. 
The  slight  paralysis  of  ocular  nerves  should  not  be  given  too 
great  weight  in  focal  diagnosis,  since  general  pressure  may  well 
produce  this  degree  of  disturbance.  There  were,  in  this  case, 
no  localizing  symptoms  whatever  of  diagnostic  worth,  a  very 
common  experience  in  intracranial  growths.  The  diagnosis, 
therefore,  was  Brain  Tumor  of  unknown  location. 

Prognosis.  The  tumor  in  this  case  developed  rapidly, 
as  shown  by  the  increase  of  symptoms  during  the  few  months 
since  they  were  first  observed.  This,  together  with  the  fact 
of  the  high  degree  of  pressure  demonstrated  at  the  operations, 
and  the  fact  that  there  is  no  likelihood  of  localizing  the  growth, 
render  the  prognosis  hopeless. 

Treatment.  Early  operation  was  imperative  in  this  case, 
if  the  eyesight  were  to  be  saved.  The  older  idea  of  postponing 
surgical  intervention  for  several  weeks  until  a  thorough 
antisyphilitic  treatment  has  been  given  is  no  longer  justified, 
even  if  the  possibility  of  determining  the  presence  of  syphilis 
were  not  at  hand  through  the  application  of  the  Wassermann 


BRAIN.  203 

test.  In  view  of  the  fact  that  localization  was  impossible, 
the  usual  right  subtemporal  decompression  was  done,  with 
immediate  relief  of  all  symptoms  and  improvement  of  the 
sight  as  already  stated.  The  hope,  in  the  second  operation, 
was  that  the  pressure  might  be  still  more  reduced  by  a 
further  opening  of  the  skull,  and  that  conceivably  the  tumor 
might  ultimately  give  indication  of  its  location.  It  is  evident 
that  the  disturbance  in  the  optic  nerve  through  pressure 
had  gone  on  too  far  to  permit  of  complete  restoration  of 
sight.  In  general,  the  decompression  operation  should  be 
undertaken  as  soon  as  possible  after  the  first  sign  of  optic 
nerve  disturbance  has  appeared. 


204  CASE   HISTORIES    IN    NEUROLOGY. 

Case  78.  U.,  twenty-nine  years  old,  foreman  in  a  factory, 
had  been  married  five  years  and  had  had  two  children. 
There  was  no  indication  of  present  or  former  venereal  disease, 
and  his  habits  were,  in  general,  good.  Beyond  headache,  which 
he  had  had  for  years,  he  had  had  no  illness  of  significance. 
Seven  months  before  he  was  examined,  which  was  on  April 
18,  1903,  he  had  undergone  an  attack  of  what  was  called 
influenza.  He  was  confined  to  his  bed  and  made  a  poor  re- 
covery, with  persistent,  chiefly  frontal,  headache,  which  had 
continued  of  about  the  same  violence,  but  with  temporary 
exacerbations.  The  pain  was  the  same  day  and  night,  and 
for  a  very  considerable  time  was  not  associated  with  vomiting. 
The  latter  part  of  March,  he  gave  up  work,  because  of  in- 
creasing general  weakness.  A  week  later  he  noticed  numbness 
in  the  right  hand,  shoulder  and  face,  and  at  about  the  same 
time  a  sudden  weakness  of  the  right  hand  developed.  The 
weakness  persisted;  the  numbness  improved.  Beyond 
slight  pain  in  the  calf  of  the  left  leg,  the  legs  were  at  that  time 
in  no  way  involved.  He  had  worn  glasses,  but  his  eyesight 
he  thought  not  impaired  by  the  present  illness.  He  had 
noticed  some  unsteadiness  of  gait.  The  urine  showed  no 
abnormality.  He  had  felt  tired  and  drowsy  and  slept  well. 
His  appetite  also  remained  satisfactory.  He  had,  however, 
lost  nearly  thirty  pounds  in  weight,  and  twelve  during  the 
past  three  weeks.  There  had  also  been  a  constant  though 
irregular  elevation  of  temperature  for  several  weeks,  the  exact 
character  and  extent  of  which  had  not  been  systematically 
obser\^ed. 

Physical  examination  at  the  first  visit  (April  18)  was  as 
follows:  Right  pupil  slightly  larger  than  the  left;  no  defect 
in  light  reaction  or  with  accommodation;  no  palsies  of  any 
cranial  nerves,  w^th  the  possible  exception  of  very  slight 
involvement  of  the  right  facial;  slight  thickness  of  speech, 
which  came  on  with  the  arm  weakness,  but  difficult  sentences 
were  correctly  repeated;  no  mental  defect  beyond  slight 
apathy.  General  sensibility  of  the  hand  was  normal, 
with  the  exception  of  well-marked  astereognosis.  The  move- 
ments of  the  hand  and  arm  were  exceed  ngly  weak  and  the 
hand  muscles  almost  completely  paralyzed.     There  was  no 


BRAIN.  205 

pain  over  the  nerve  trunks.  The  arm  reflexes  were  active 
in  both  sides  and  showed  no  decided  inequahty.  There  was 
a  very  slight  Romberg  sign  but  no  abnormality  of  the  legs 
or  feet,  sensory  or  motor.  The  knee  jerks  were  active, 
but  within  normal  limits;  Achilles  jerks  present;  no  Babinski. 
The  pulse  was  140,  with  correspondingly  rapid  respiration, 

On  April  21,  three  days  later,  it  was  reported  that  he  had 
had  attacks  of  nausea  and  vomiting  for  some  time,  but 
apparently  associated  with  the  taking  of  food,  and  not 
projectile  in  character.  On  that  day  he  had  had  a  distinct 
spasm  of  the  right  hand  and  arm.  His  wife  stated  that  he 
had  grown  irritable  and  unreasonable.  The  pulse  remained 
rapid.  There  was  possible  exceedingly  slight  impairment  of 
tactile  sensibility  of  the  right  hand.  The  astereognosis 
was  complete  as  before.  There  was  no  recognition  whatever 
of  various  objects  placed  in  the  hand,  as,  for  example,  a 
watch,  a  small  box,  a  fifty-cent  piece.  Electrical  examination 
gave  satisfactory  response  to  farad  ism  from  nerves  and 
muscles;  galvanism,  quick  response;  CaC  greater  than  AnC; 
no  indication  of  R.  D.  and  no  noteworthy  difference  on  the 
two  sides  In  the  muscles  examined.  The  right  hand  and 
arm  were  almost  completely  paralyzed.  Pupils  dilated  with 
hematroplne  showed  marked  physiological  cupping;  unusual 
arrangement  of  vessels;  outlines  of  disks  for  the  most  part 
clear  but  somewhat  clouded  on  the  nasal  side  of  right  eye; 
no  hemorrhage  and  a  suspicion  merely  of  beginning  choking. 
The  vision  was  unimpaired.  Iodide  of  potash  was  given  In 
Increasing  doses  but  without  effect. 

The  following  further  points  of  interest  developed:  Spas- 
modic movements  of  the  face,  on  both  sides,  with  temporary 
loss  of  speech,  but  without  marked  involvement  of  the  leg, 
and  many  spasms  of  the  right  hand,  lasting  about  an  hour, 
supervened.  The  abdominal  reflex  became  greater  on  the 
left  than  on  the  right;  the  knee  jerks,  greater  right  than  left; 
there  was  marked  ankle  clonus  right,  none  left;  plantar 
reflexes  were  present  and  apparently  normal.  Muscle  sense 
of  toes  was  unimpaired,  but  astereognosis  of  the  right  hand 
persisted.  The  temperatures  had  remained  elevated ;  respira- 
tion, 36;    pulse,  136;    blood  pressure,  14O0     There  had  been 


206 


CASE   HISTORIES    IN    NEUROLOGY. 


diarrhea  for  several  days,  with  rapid  change  for  the  worse 
in  the  past  two  weeks ;  he  became  \'ery  weak.  The  leucocyte 
count  was  12,000.  Further  examination  of  the  chest  showed 
no  definite  signs  of  disease.  The  tuberculin  test  was  not 
attempted  oa  account  of  persistent  elevation  of  temperature. 

Operation.  The  skull  w^as  opened  on  May  i,  over  the 
right  arm  area,  extending  also  posterior  to  the  central  fissure. 
A  tumor  was  at  once  disclosed  and  in  large  part  removed, 
chiefly  anterior  to  the  fissure.  The  tumor  appeared  to  be 
semi-encapsulated;  the  temperature  at  the  operation  was 
103.5.  Immediate  recovery  from  its  effects  was  satisfactory; 
there  was  no  vomiting  at  any  time.  Subsequent  examination 
showed  the  right  pupil  larger  than  the  left,  with  adequate 
light  reaction  on  both  sides;  there  was  much  difficulty  with 
speech,  of  the  motor  type;  the  right  arm  was  completely  para- 
lyzed, and  the  right  leg  partially  so;  the  knee  jerk  was  greater 
on  the  right;    there  was    Babinski    sign    and  ankle  clonus. 


Fig.  34.     Cask  7S.     Showing  Location  of  Tumor  Productive  of  Astereognosis. 


There  was  temporary  improvement  in  some  of  these  symptoms, 
but  in  general  the  patient  gradually  failed.  The  sensibility 
of  the  right  arm  was  as  before  the  operation,  and  the  astere- 
ognosis persisted.     There  was  some  bulging  of  the  returned 


BRAIN. 


207 


bone  flap  but  no  signs  of  sepsis;  the  temperature  remained 
elevated.     He  died  May  28,  four  weeks  after  the  operation. 

Autopsy.  The  autopsy  revealed  general  miliary  tubercu- 
losis involving  all  the  internal  organs,  with  a  primary  focus 
in  the  prostate  or  seminal  vesicles.  The  brain  tumor  was 
also  tuberculous  in  character,  with  several  small  adjoin- 
ing but  discrete  tumors  in  its  immed  ate  neighborhood. 

Diagnosis.  A  definite  diagnosis  of  tuberculosis,  though 
strongly  suspected  during  life,  was  not  made.  The  tempera- 
ture was  highly  suspicious,  but  it  was  difficult  to  bring  it  into 
immediate  connection  with  a  well-defined  and  localizable 
brain  tumor.  That  so  large  a  tuberculous  mass  should  have 
been  present  with  an  acute  miliary  process  is  a  matter  of 
interest.     The  motor  weakness  of  the  right  arm,   together 


Fig.  35.    Cortical  Areas. 

with  a  perfectly  developed  astereognosis,  pointed  strongly 
toward  a  lesion  of  the  arm  area  of  the  left  cortex,  presumably 
extending  backward  into  the  sensory  zone.  (See  Fig.  35.) 
This  assumption  was  justified  both  by  the  operation  and  by 
the  autopsy. 

Prognosis.  In  view  of  the  generalized  tuberculosis,  the 
prognosis  of  the  case  was  hopeless.  It  is  not  probable 
that  the  operation  influenced  in  any  way  his  length  of  life. 


208  CASE   HISTORIES    IN    NEUROLOGY. 

Treatment.  In  so  sharply  localized  a  lesion,  operation  was 
justified,  even  in  the  presence  of  temperature,  which,  although 
unlikely,  it  was  conceived  possible  might  be  due  to  an  inde- 
pendent cause. 


BRAIN.  209 

Case  79.  R.,  a  man  thirty  years  old,  the  father  of  two  chil- 
dren, had  had  typhoid  fever  but  In  general  had  been  well. 
He  noticed  no  difficulty  until  about  six  or  eight  months  before 
being  seen,  in  October,  1907.  He  had  had  no  nausea  or  vomit- 
ing but  had  had  some  little  difficulty  with  gastric  digestion, 
accompanied  by  a  sense  of  burning  and  a  feeling  of  weight. 
About  four  weeks  before  being  seen,  while  driving  in  an  auto- 
mobile, he  noticed  a  sense  of  irritation  in  the  right  eye, 
which  was  attributed  to  dust.  The  sensation  so  originated 
seemed,  however,  to  spread  about  the  eye  and  persisted. 
Later,  this  became  a  feeling  of  heat  extending  over  the  right 
side  of  the  face  and  over  the  upper  arm.  He  also  occasionally 
had  disordered  feelings  in  the  right  hand.  Four  days  after 
the  onset  of  this  disturbance,  there  was  a  rapid  develop- 
ment of  left  facial  paralysis.  A  week  later,  the  mouth  was 
completely  paralyzed  on  that  side.  There  was  also  further 
extension  of  the  area  of  disturbed  sensation  involving  the 
upper  part  of  the  chest.  On  more  than  one  occasion  there 
had  been  a  severe  "  cramp  "  in  the  paralyzed  side  of  the  face. 
A  paralysis  of  the  left  sixth  nerve  had  also  developed  during 
a  period  of  two  days.  There  was  no  diplopia,  but  the  patient 
had  long  since  learned  to  ignore  the  right  eye,  owing  to  a  former 
squint  which  had  been  surgically  corrected.  He  had  had 
absolutely  no  headache,  but  had  observed  some  vertigo 
when  his  head  was  tipped  back,  and  unsteadiness  in  standing, 
particularly  when  he  attempted  to  turn  quickly.  He  had 
no  further  feeling  of  discomfort  beyond  what  he  described 
as  "  a  disagreeable  taste  in  the  mouth."  He  had  noticed  no 
disturbance  of  hearing. 

Examination  showed  no  changes  in  the  fundus  (the  left 
eye  only  examined) ;  there  was  practically  a  complete  pa- 
ralysis of  the  left  external  rectus ;  the  muscles  supplied  by  the 
third  nerve  were  unaffected;  there  was  a  complete  paralysis 
of  all  muscles  supplied  by  the  left  seventh  nerve,  including  the 
platysma.  The  nerves  below  the  pons  were  unaffected. 
On  the  right  side,  involving  one  half  the  head,  the  shoulder 
and  upper  arm,  the  skin  was  paresthetic,  with  some  objective 
blunting  of  sensation.  There  was  no  pain  whatever  over  the 
nerve    trunks.      The    knee   jerks   were   active   and    normal; 


210  CASE    HISTORIES    IN    NEUROLOGY. 

wrist  jerks  were  slightly  present;  the  abdominal  reflexes  were 
active. 

When  seen  about  three  weeks  later,  he  had  lost  power  in 
the  left  masseter  muscle  (supplied  by  the  fifth  nerve).  One 
half  the  tongue,  the  gums  and  the  left  cheek  also  had  become 
numb.  This  had  come  on  in  the  course  of  two  days.  Taste 
was  somewhat  affected  on  the  left  side.  For  several  nights 
there  had  been  considerable  pain  over  the  left  mastoid  bone, 
throbbing  and  intermittent  in  character.  There  was  an  es- 
pecially tender  spot  under  the  left  ear,  but  the  entire  side  of 
the  face  was  sensitive  to  touch .  There  had  been  no  ear  suppura- 
tion. Since  the  previous  visit  he  had  had  considerable  nau- 
sea on  two  occasions  after  eating,  and  also  in  the  morning 
on  rising.  His  stomach  had  been  out  of  order  for  two  weeks, 
and  he  had  given  up  iodide  of  potash,  which  had  been  pre- 
scribed. He  had  been  languid,  physically  weak  and  had 
lost  weight.  There  still  was  no  definite  headache,  and  some 
improvement  in  the  movement  of  the  left  masseter  was 
noticed. 

Physical  examination  at  this  time  showed  weakness  of  the 
right  internal  rectus  (third  nerve).  The  globe  could  not 
be  moved  beyond  the  middle  line.  There  was  definite  weak- 
ness of  the  left  masseter.  Contraction  was  still  possible  but 
markedly  less  than  on  the  right.  The  jaw  could  not  be  moved 
beyond  the  line  of  the  teeth  toward  the  right  (pterygoids). 
The  whole  sensory  distribution  of  the  fifth  nerve  was  blunted 
on  the  right  side,  with  a  further  extension  of  disturbed  sen- 
sation as  before  noted.  The  gums  and  inside  of  the  mouth, 
together  with  one  half  the  tongue,  remained  numb.  There  was 
reaction  of  degeneration  in  the  paralyzed  facial  nerve. 
The  palatal  reflexes  were  lacking;  there  was  distinct  vertigo 
when  he  tipped  his  head  backward.  Examination  of  the  facial 
nerve  showed  slight  faradic  response  on  direct  and  indirect 
stimulation,  with  slow  response  to  galvanism,  the  CaC  greater 
than  AnC;  partial  R.  D. 

One  month  later,  the  areas  of  disturbed  sensation  extended 
over  the  whole  right  side,  involving  the  foot.  He  vomited 
regularly  every  morning  before  breakfast  and  was  somewhat 
nauseated.     The  nausea  was  worse  when  lying  down.     He 


BRAIN.  211 

had  no  headache  whatever;  his  gait  was  increasingly  uncer- 
tain and  he  thought  he  staggered  especially  toward  the  right. 
The  optic  disks  remained  absolutely  normal  and,  in  general, 
his  eyes  had  not  changed.  There  was  still  conjugate  deviation 
toward  the  right;  reaction  to  light  was  normal.  Taste  was 
not  properly  appreciated  on  either  side  of  the  tongue;  smell 
was  unaffected ;  the  reflexes  were  in  general  active ;  there  was 
no  definite  Romberg  sign;  he  had  been  extremely  weak  and 
had  lost  probably  fifteen  or  twenty  pounds.  He  died,  March 
22,  1908,  with  the  development  of  a  paralysis  of  the  sixth, 
seventh  and  eighth  nerves,  associated  with  considerable  ataxia 
and  final  throat  involvement. 

Autopsy.  The  autopsy  in  this  case  revealed  an  extensive 
non-infiltrating  Tumor  of  the  dorsal  portion  of  the  pons 
throughout  a  considerable  part  of  its  extent.  The  growth 
did  not  give  rise  to  any  marked  distortion  or  increase  in  size 
of  the  region  of  the  brain  stem  involved.  Histological 
examination  showed  the  tumor  to  be  a  sarcoma. 

Diagnosis.  The  signs  in  this  case  all  pointed  toward  a 
lesion,  progressive  in  character,  of  the  right  side  of  the  pons. 
The  fifth,  sixth,  seventh  and  later  the  third  nerve  of  that  side 
were  involved.  Of  importance  in  the  diagnosis  of  pontine 
lesions  is  the  conjugate  deviation  of  the  eyes,  markedly  pres- 
ent in  this-  case.  It  is  of  special  interest  that  throughout 
the  course  of  the  disease  the  intracranial  pressure  was  so 
slightly  raised  that  choked  disk  did  not  occur.  Headache, 
also,  was  not  a  conspicuous  symptom,  and  vomiting  was  not 
extreme,  certainly  not  until  toward  the  end  of  life.  In  general, 
tumor  in  the  posterior  fossa  gives  rise  to  early  choked  disk, 
headache  and  vomiting.  Their  absence  in  this  case  was  due 
to  the  infiltrating  character  of  the  growth. 

Prognosis.  Operation  was  not  seriously  considered  owing 
to  the  position  of  the  growth  and  to  the  consequent  impossi- 
bility of  its  removal. 

Treatment.     Treatment  was  unavailing. 


212  CASE    HISTORIES    IN    NEUROLOGY. 

Case  80.  O.,  a  teacher  of  forty-three,  gave  the  following- 
history.  Two  weeks  before  being  seen  she  suddenly  slipped 
on  a  waxed  floor  and  fell,  striking  her  face  on  the  right  side 
withbut  having  extended  her  arm  to  break  the  fall.  She  sat 
up  at  once  but  was  dazed  and  unable  to  stand.  How  she  hap- 
pened to  fall,  beyond  what  has  been  stated,  she  could  not 
remember.  She  was  finally  able  to  go  down  a  flight  of  stairs 
alone.  There  was  slight  bleeding  from  the  mouth  through 
a  superficial  cut.  She  was  not  nauseated,  gradually  became 
less  confused  and  soon  felt  decidedly  better.  A  swelling 
about  the  size  of  an  egg  developed  at  the  point  where  she 
struck,  but  this  did  not  interfere  with  her  sleep  that  night. 
The  next  morning  she  considered  herself  well.  She  had  little 
pain  and  the  swelling  had  begun  to  subside.  She  was  able 
to  do  some  typewriting,  and  had  no  headache  during  the  day. 
At  the  end  of  a  week,  except  for  some  head  pain  in  the  morn- 
ing, she  suffered  no  discomfort.  Six  days  after  her  fall  she 
had  a  very  exacting  day  and  the  following  morning  awoke 
with  an  extremely  severe  headache,  chiefly  in  the  left  frontal 
region.  She  was  faint  and  vomited  after  breakfast.  The 
pain  continued  the  following  day,  but  she  was  able  to  go  out. 
Several  days  later,  headache  became  persistent,  extended  over 
the  vertex  and  was  sufficiently  severe  to  give  her  considerable 
discomfort.  She  had  formerly  had  migranoid  headaches 
very  infrequently.  Of  late,  they  had  returned  at  shorter 
intervals.  She  had  begun  to  worry  considerably  over  her 
condition  and  feared  her  memory  was  failing. 

On  the  supposition  that  her  condition  was  a  very  natural 
result  of  the  experience  through  which  she  had  passed, 
a  rest  away  from  her  work  was  advised.  Following  this  sug- 
gestion she  went  to  a  seaside  place,  but  at  once  grew  worse. 
Headache  was  extreme  and  considerable  confusion  of  speech 
developed.  She  returned  to  Boston  in  a  deplorable  condition, 
hardly  able  to  walk  or  speak  and  evidently  extremely  ill. 
She  was  at  once  sent  to  a  hospital,  where  the  following  condi- 
tions were  noted. 

She  had  developed  extreme  difficulty  in  expressing  herself, 
and  at  times  appeared  almost  delirious.  The  pulse  was  regu- 
lar and  rather  slow,  60.     She  sank  rapidly  into  a  stuporous 


BRAIN.  213 

state,  with  incontinence  of  urine.  She  could  be  roused  only 
with  the  greatest  difficulty  and  then  only  for  a  brief  period. 
Occasionally,  she  shook  her  head  in  answer  to  a  question 
and  showed  some  slight  sign  of  recognition  of  her  situation. 
In  general,  she  lay  with  eyes  closed  and  apparently  entirely 
indifferent  to  her  surroundings.  On  raising  the  lids,  the  eyes 
were  expressionless.  The  pupils  were  not  widely  dilated  and 
reacted  properly  to  light.  She  did  not  protrude  her  tongue  on 
request.  The  temperature  became  slightly  elevated  and  the 
pulse  varied  from  54  to  60  and  was  of  good  quality.  After 
being  two  days  at  the  hospital,  spasmodic  movements  of  the 
right  arm  and  hand  developed.  These  were  intermittent 
and  associated  with  much  rigidity,  the  fingers  being  tightly 
pressed  into  the  palms.  Both  legs  were  continuously  moved, 
but  not  spasmodically.  An  examination  on  the  evening  of 
that  day  showed  the  arm  reflexes  all  active,  probably  more  so 
on  the  right  than  on  the  left.  The  abdominal  and  epigastric 
reflexes  were  not  obtained  on  the  right  side.  The  knee  jerks 
were  both  very  active,  with  double  clonus  and  marked  Babin- 
ski  response.  On  the  right  there  were  athetoid  movements 
of  the  toes.  This  was  also  noticed  in  the  right  hand,  together 
with  much  tremor  simulating  a  clonus  when  any  movement 
was  attempted.  At  this  time  the  patient  was  very  restless 
and  delirious.  On  account  of  her  incapacity  to  fix  her  eyes, 
a  fundus  examination  was  extremely  difficult,  but  a  choked 
disk  in  both  eyes  was  strongly  suspected. 

Operation  was  decided  upon.  A  large  osteoplastic  flap 
was  laid  back  on  the  left  side,  including  the  motor  area. 
The  dura  was  under  high  tension.  An  incision  led  to  a  slight 
escape  of  serum,  but  no  blood.  A  trephine  on  the  opposite 
side  showed  the  same  condition.  No  hemorrhage  was  revealed. 
The  coma  was  so  deep  that  a  small  amount  of  ether  only  was 
necessary  for  anesthesia.  The  pulse  during  the  operation 
was  from  90  to  120.  The  temperature  was  somewhat  elevated, 
but  in  general  the  recovery  from  the  operation  was  satisfac- 
tory. During  the  following  night  she  was  able  to  swallow,  but 
the  temperature  rose  to  103  + .  The  following  morning  it  went 
down  to  101°,  with  a  pulse  of  132.  There  were  slight  signs  of 
returning  consciousness,  with  twitching  of  the  lids  and  move- 


214 


CASE   HISTORIES    IN    NEUROLOGY. 


ments  of  both  hands,  the  left  more  than  the  right.  The  im- 
pro\ement  was,  however,  merely  temporary,  and  she  died 
three  days  later  without  recovering  consciousness. 

Autopsy.  The  autopsy  re\'ealed  no  external  hemorrhage 
whatever,  either  on  the  convexities  or  on  the  base  of  the  brain. 
Section  revealed   a   large   infiltrating   tumor  occupying   the 


Fig.  36.     Case  80.     Showing  Location  and  Extent  of  Tumor. 

greater  part  of  the  left  temporal  lobe.  The  growth  was  vas- 
cular, hemorrhagic  in  some  places  and  necrotic  in  others. 
There  were  adhesions  of  the  dura  over  the  tegmen  tympani, 
but  without  evidence  of  disease  of  either  ear. 

Diagnosis.  A  definite  diagnosis  in  this  case  was  not  made. 
The  entire  absence  of  symptoms  in  the  history  pointing  to 
intracranial  pressure  together  with  a  violent  fall,  striking 
the  head,  led  to  the  supposition  that  the  patient  was  suffering 
from  the  immediate  effects  of  this  violence  and  that  her  later 
symptoms  were  due  presumably  to  a  hemorrhage  indirectly 
resultant  therefrom.  The  facts  of  the  case  probably  were, 
that  the  Tumor  had  existed  for  several  years,  had  been  so 
infiltrating  in  character  and  insidious  in  onset  and  had  given 
rise  to  so  little  pressure  that  the  general  symptoms  of  tumor 
had  not  developed.  When  the  patient  fell,  the  absence  of  in- 
jury to  her  hands  undoubtedly  signified  that  she  was  uncon- 
scious at  the  time  and  that  the  fall  was  a  consequence  of 
the  attack  which  suddenly  came  on.  The  injury  resulting 
very  probably  led  to  certain  hemorrhages  in  the  vascular 
tumor  and  undoubtedly  precipitated  the  onset  of  the  fatal 


BRAIN.  215 

outcome.  The  case  illustrates  the  now  well-recognized  fact 
that  tumors  of  the  brain,  if  lying  in  silent  areas,  may  exist 
for  long  periods  without  giving  rise  to  signs  or  symptoms, 
and  also  that  trauma  may  precipitate  a  fatal  outcome  under 
such  conditions,  though  not  in  itself  to  be  regarded  as  causa- 
tive of  tumor  formation.  The  final  symptoms  were  undoubt- 
edly due  to  general  pressure  leading  to  spasmodic  movements 
of  the  opposite  side  of  the  body,  choked  disks  and  stupor. 
The  primary  supposition  when  the  operation  was  undertaken 
was  that  hemorrhage  might  be  found.  Tumor  was  con- 
sidered a  wholly  unlikely  explanation  of  the  condition. 

Prognosis.  The  condition  as  revealed  by  autopsy  was 
entirely  irremediable. 

Treatment.  The  treatment  is  sufficiently  indicated  in  the 
foregoing  description. 


2l6  CASE    HISTORIES    IN    NEUROLOGY. 

Case  8i.  L.,  a  young  man,  twenty-two  years  of  age, 
was  admitted  to  a  hospital  July  19,  190 1.  He  was  unmarried, 
and  by  occupation  an  expressman.  His  family  history  was 
negative  except  that  his  mother  had  suffered  from  some  sort 
of  paralysis  and  was  unable  to  walk  for  a  time  previous  to 
her  death.  In  April,  1901,  he  was  treated  at  a  hospital  for 
an  unascertained  disease.  He  remained  for  four  weeks, 
leaving  the  hospital,  he  thought,  well.  About  a  week  before 
his  final  entrance  to  the  hospital,  in  July,  the  patient  stated 
that  he  was  found  unconscious  in  a  field  and  was  taken  home 
and  put  to  bed.  He  thought  that  he  was  more  or  less  uncon- 
scious for  a  week,  and  knew  only  what  was  taking  place  in 
that  time  from  what  was  told  him.  His  family  informed 
him  that  he  talked  and  answered  questions  during  this  week 
of  apparent  unconsciousness.  When  he  regained  conscious- 
ness, he  found  his  sight  impaired,  and  it  failed  rapidly  there- 
after, until  finally  he  could  only  distinguish  light  from 
darkness.  He  complained  of  severe  headache,  which  had  been 
present  since  this  attack.  The  foregoing  statements  are  not 
to  be  regarded  as  entirely  satisfactory  on  account  of  the  men- 
tal condition  of  the  patient.  He  answered  questions  quickly 
on  being  aroused,  but  his  statements  did  not  always  agree. 
His  mental  state  varied  from  time  to  time. 

Physical  examination  after  entrance  to  the  hospital 
showed  a  well-developed  man  of  moderate  intelligence. 
His  pupils  were  dilated,  reacted  sluggishly  to  light,  but  did 
not  accommodate.  There  was  no  paralysis  of  the  ocular 
muscles.  The  tongue  was  heavily  coated  and  there  was 
much  sordes.  The  heart  was  normal;  the  pulse,  45.  The 
lungs  showed  no  abnormalities,  nor  did  the  abdominal  organs. 
There  was  no  BabinskI  phenomenon  or  clonus,  and  no  loss 
of  sensation  or  motion  discoverable.  The  urine  was  negative. 
During  the  following  month  the  patient  remained  in  a  semi- 
conscious condition;  he  could  be  aroused,  but  made  contra- 
dictory answers  to  questions  asked.  Headache  and  vertigo 
persisted,  and  there  was  almost  daily  vomiting  in  spite  of 
the  maintenance  of  a  good  appetite.  No  paralysis  was  dis- 
covered during  this  time.  On  August  6,  there  was  a  choked 
disk  of  the  right  eye  of  about  2  millimeters  elevation;    the 


BRAIN.  217 

vessels  were  very  tortuous.  The  left  eye  showed  complete 
optic  atrophy  with  arteries  of  small  caliber.  On  August  9, 
mental  confusion  regarding  place  and  time  manifested  itself, 
with  somewhat  less  headache.  On  August  30,  a  left  internal 
strabismus  appeared,  which  was  the  first  possible  localizing 
symptom.  There  was  also  a  questionable  paresis  of  one 
seventh  nerve,  with  very  slight  numbness  of  the  left  side  of 
the  face.  Hearing  and  the  other  cranial  nerves  showed  no 
involvement.  Knee  jerks  and  plantar  reflexes  were  normal. 
At  this  time  it  was  noticed  that  the  swelling  of  the  nerve 
head  in  the  right  eye  had  greatly  diminished;  the  outline 
of  the  disk  could  be  faintly  made  out  and  the  disk  had  a  dis- 
tinct, glossy,  white  color;  the  vessels  were  less  tortuous. 
The  pupils  no  longer  responded  to  light,  and  there  was  no 
light  perception  in  either  eye.  From  this  time  on  the  patient 
grew  steadily  worse,  with  periods,  however,  of  temporary 
improvement.  On  October  23,  he  had  a  convulsion  which 
lasted  about  five  minutes,  without  loss  of  consciousness. 
On  November  i,  he  was  stuporous.  Iodide  of  potassium  had 
had  no  effect  upon  his  condition.  On  February  4,  it  was 
noticed  that  convulsions  were  occurring  more  frequently, 
and  that  each  was  more  severe  than  the  preceding.  During 
these  attacks,  the  patient  vomited  food  which  had  been  im- 
properly masticated.  On  February  15,  he  had  a  severe 
convulsion ;  he  perspired  freely ;  the  breathing  was  stertorous ; 
tonic  and  clonic  spasm  developed,  but  with  a  satisfactory 
pulse.  The  convulsion  subsided  gradually  under  ether.  If 
touched,  another  convulsion  was  excited.  From  this  time  on 
to  his  death,  which  occurred  on  March  2,  there  was  a  recur- 
rence of  convulsions,  deepening  coma,  final  high  temperature 
(106.2°),  with  pulse  of  140,  and  death  quietly  in  spite  of  vigor- 
ous  stimulation. 

Autopsy.  The  left  pleural  cavity  was  completely  obliter- 
ated by  old  fibrinous  adhesions.  The  lungs  were  distended 
and  contained  various  small  hemorrhagic  areas.  The  spleen, 
stomach,  intestines,  pancreas,  liver  and  kidneys  showed  noth- 
ing abnormal.  The  skull  was  thin;  the  dura  not  adherent. 
At  the  base  of  the  skull  in  the  middle  line,  occupying  the  region 
of  the  pituitary  body,  was  a  tumor  which  also  Involved  the 


21 8  CASE   HISTORIES    IN    NEUROLOGY. 

optic  chiasm  and  apparently  originated  from  it.  The  optic 
tract  on  the  right  side  was  grayish-white  and  of  normal 
appearance;  on  the  left,  translucent.  The  tumor  was  about 
the  size  of  an  English  walnut,  4x3  centimeters  in  diameter. 
The  arteries  at  the  base  were  normal.  Both  lateral  ventricles 
were  greatly  dilated,  due  to  pressure  by  the  tumor  in  the  neigh- 
borhood of  the  foramen  of  Munro.  The  anterior  portion  of 
the  third  ventricle  was  obliterated,  leading  to  compression 
of  the  choroid  plexuses.  The  left  optic  tract  was  apparently 
destroyed  by  the  tumor.  The  right  optic  tract  was  markedly 
involved  at  one  point,  though  not  completely  obliterated. 
The  third  nerve  showed  no  involvement  on  either  side. 
In  the  specimen  as  finally  received  for  examination  no  further 
statement  was  to  be  made  regarding  the  cranial  nerves. 
On  section,  the  tumor  consisted  of  a  larger  cyst  about  one  cen- 
timeter in  diameter,  and  many  smaller  cysts  filled  with  a  coagu- 
lated, translucent  mass.  In  the  solid  portion  which  comprised 
the  remainder  of  the  tumor  there  were  a  considerable  number 
of  fresh  hemorrhages. 

Microscopic  examination  showed  a  highly  cellular,  new 
growth,  interspersed  with  many  new-formed  blood  vessels 
and  cysts.  The  arrangement  of  the  cells  was  irregular  and 
without  a  definite  stroma.  The  cells  composing  the  growth 
were  round,  with  many  transitional  forms  toward  the  spindle 
variety.    The  growth  should  be  included  under  the  sarcomata. 

Diagnosis  and  Remarks.  The  diagnosis  of  Tumor  in  this 
case  was  not  difhcult,  owing  to  the  manifest  signs  of  intra- 
cranial pressure.  Its  location  was  less  simple  and  in  fact 
was  not  definitely  determined  during  life.  The  points  of 
special  interest  in  the  case  are:  (i)  The  mode  of  onset  and 
the  mental  state  of  the  patient ;  (2)  the  occurrence  and  signifi- 
cance of  early  optic  nerve  atrophy ;  (3)  convulsions  and  their 
significance;  (4)  the  slight  involvement  of  cranial  nerves 
other  than  the  optic  nerves;  (5)  the  tendency  to  remission 
of  symptoms ;  (6)  the  presence  of  a  tumor  in  the  neighborhood 
of,  and  probably  involving,  the  hypophysis,  without  the  pro- 
duction of  acromegaly. 

The  case  shows  that  the  signs  of  tumor  may  come  on  sud- 
denly (see  also  Case  80),  and  that  marked  mental  disturbance 


BRAIN.  219 

may  occur  as  a  result  of  tumor  far  removed  from  the  cortex. 
The  early  optic  nerve  atrophy  often  indicates  pressure  di- 
rectly upon  the  optic  nerves  or  tracts.  The  small  localizing 
value  of  convulsions  is  demonstrated  by  this  case.  That 
acromegaly  did  not  develop  is  no  doubt  due  to  the  fact 
that  the  prehypophysis  was  not  involved. 

Prognosis  and  Treatment.  Had  a  diagnosis  been  made,  the 
prognosis  was  in  any  event  hopeless,  since  removal  of  the 
tumor  was  impossible. 


220  CASE    HISTORIES    IN    NEUROLOGY. 

Case  82.  O.,  a  boy  of  five  and  a  half,  was  a  second  child. 
There  was  no  difficulty  at  his  birth  and  he  appeared  normal 
as  an  infant.  At  the  age  of  two,  he  had  a  convulsion  from 
which  he  quickh^  recovered.  Since  that  time  there  had  been 
difficulty  with  digestion.  When  he  was  about  three  and  a 
half  years  old  he  began  to  complain  of  his  head,  which  appeared 
to  be  painful;  the  attacks  of  pain,  however,  were  of  very 
transient  duration  and  were  always  relieved  by  vomiting. 
A  year  later  he  had  many  attacks  characterized  by  sudden 
retraction  of  the  head,  followed  by  screaming.  He  was  irri- 
table and  finally  had  a  severe  general  convulsion,  followed  by 
others  of  slighter  degree.  He  was,  in  general,  slow  in  develop- 
ment and  had  not  learned  to  dress  himself  or  completely 
to  control  the  sphincters. 

Examination  showed  the  circumference  of  the  head  to  be 
twenty-one  and  a  quarter  inches.  The  distance  between  the 
parietal  eminences  was  ten  and  a  half  inches;  from  the  gla- 
bella to  the  inion,  fourteen  inches;  the  forehead,  especially 
over  the  eyes,  was  particularly  prominent  and  the  whole 
head,  as  shown  by  the  measurements,  was  large.  The  eyes 
gave  a  good  light  reaction ;  there  was  a  very  slight  internal 
squint.  He  was  clumsy  and  ataxic  in  his  movements  and 
walked  with  a  marked  ataxic  gait.  The  knee  jerks  and 
plantar  reflexes  were  normal.  He  had,  when  seen,  for  some- 
time been  free  from  convulsive  seizures.  The  heart  showed 
no  abnormality. 

Diagnosis.  This  is  a  backward  child  of  the  Hydrocephalic 
type,  as  shown  by  the  disproportionate  size  of  the  head,  asso- 
ciated with  manifest  defects  of  development. 

Prognosis  and  Treatment.  The  child  should  live  to  adult 
life  and  with  proper  training  should  be  able  to  care  properly 
for  himself.  The  epileptiform  seizures  should  be  controlled 
by  the  bromides,  attention  to  diet  and  strict  hygiene.  Noth- 
ing can  be  done  to  alleviate  the  hydrocephalus  itself,  which 
undoubtedly,  in  this  case,  has  reached  such  a  degree  that  the 
brain  is  unable  to  perform  its  functions  properly.  There  is, 
however,  little  reason  to  fear  an  increase  of  the  hydrocephalus. 
An  equilibrium  has  probably  been  reached  which  is  rarely  the 
case  when  the  process  begins  at  or  about  birth. 


BRAIN.  221 

Case  83.  G.,  a  man  of  fifty-nine,  six  months  before  being 
seen  had  noticed  diplopia  due  to  an  external  strabismus, 
the  left  eye  being  affected.  One  month  later,  the  left  eyelid 
began  to  droop.  This  was  followed  by  a  similar  drooping 
of  the  right  lid.  He  was  otherwise  well  and  had  no  headache, 
vomiting  or  muscular  weakness.  His  habits  were  good ; 
he  did  not  use  alcohol  or  tobacco  and  denied  venereal  disease. 

Examination  showed  ptosis  of  the  right  lid  with  the  same 
condition  in  less  degree  on  the  left.  The  third,  fourth  and 
sixth  nerves  were  all  involved  to  a  certain  degree  in  both 
eyes,  which  led  to  a  practical  immobility  of  the  eyeballs. 
Diplopia  was  particularly  marked  on  looking  forward  or 
upward,  the  false  image  being  above  and  to  the  left  of  the 
true  image.  The  pupils  reacted  normally  to  light.  The 
knee  jerks  were  present  and  equal ;  there  was  no  ankle  clonus, 
Babinski  sign  or  Romberg.  The  urine  showed  no  albumin  or 
sugar.     The  tongue,  lips,  face  and  palate  were  not  involved. 

Under  alternating  treatment  with  strychnia  and  iodide  of 
potash,  there  was  distinct  improvement.  Somewhat  over  a 
year  after  being  first  seen,  he  was  able  to  open  his  eyes  more 
effectually,  the  right  eye  being  less  involved  than  the  left. 
Movements  of  the  left  eye  downward,  upward,  inward  and 
outward  were  limited  in  extent.  The  same  was  true  of  the 
right  eye  on  attempted  downward  and  inward  motion. 
The  movements  upward  and  outward  were,  however,  prac- 
tically normal.  A  year  later  there  was  further  slight  improve- 
ment, but  the  movements  of  the  left  eye  remained  affected. 
There  was  no  extension  at  any  time  to  other  cranial  nerves 
or  to  more  distant  parts  of  the  nervous  system. 

Diagnosis.  This  is  a  case  of  chronic  Ophthalmoplegia  of 
unknown  etiology.  There  was  no  evidence  that  the  patient 
had  suffered  from  any  acute  infection  immediately  preceding 
the  onset  of  the  ocular  trouble  nor  had  he  been  addicted  to 
the  over-use  of  alcohol.  There  was  also  no  evidence  in  the 
face  of  his  denial  that  the  difficulty  was  due  to  syphilis. 
It  must,  therefore,  be  assumed  that  the  lesion  in  this  case  was 
an  involvement  of  the  ocular  nerves,  sparing,  however, 
those  branches  which  regulate  the  pupillary  reactions. 
This  affection  corresponds  in  a  general  way  to  the  progressive 


222  CASE   HISTORIES   IN   NEUROLOGY. 

muscular  atrophy  of  the  lower  cranial  ner\^es  (see  Case  84), 
differing,  however,  in  the  fact  that  it  has  not  been  steadily 
progressive  and  has  yielded  at  least  in  a  certain  degree  to 
treatment. 

Prognosis.  It  is  not  probable  that  the  affection  will 
spread  beyond  its  present  limits.  Improvement  is  likely 
to  be  maintained,  but  complete  restoration  of  function  is 
improbable. 

Treatment.  It  is  difficult  in  this  case  to  say  whether 
the  treatment  instituted  was  efficacious  or  whether  the  im- 
provement resulted  from  purely  natural  causes.  Iodide  of 
potash  was  administered  for  considerable  periods  up  to  150 
grains  a  day.  Strychnia  was  also  given  in  vigorous  doses. 
The  improvement  seemed  to  be  equally  marked  under  either 
form  of  medication. 


BRAIN.  22,3 

Case  84.  I.,  a  man  of  fifty-one,  a  painter  by  occupation  and 
the  father  of  five  children,  had  noticed  for  about  a  year"  twitch- 
ing "  of  the  right  arm  and  later  of  the  left  arm,  associated 
with  weakness  in  the  use  of  the  hand.  Coincident  with  this, 
indistinctness  of  speech  developed,  which  had  grown  progres- 
sively worse.  For  from  three  to  four  months  he  had  had  diffi- 
culty in  swallowing  "  even  water."  He  had  had  no  pain 
or  feelings  of  numbness.  He  had  also  noticed  increasing 
incapacity  to  control  emotional  expression.  He  laughed  and 
wept  frequently  without  cause.  Other  than  in  the  respects 
stated  he  had  been  well  except  for  a  possible  lead  paralysis 
some  six  years  before. 

Examination  showed  the  pupils  normal,  both  to  light  and 
on  accommodation;  optic  disks  clear;  no  paralysis  of  the 
ocular  nerves.  Both  facial  nerves  were  distinctly  weak  in 
all  branches.  The  trigeminal  nerve  was  normal.  The  tongue 
was  protruded  with  great  difficulty  and  imperfectly.  It  was 
soft,  atrophic  and  showed  much  fibrillation.  Speech  was  al- 
most unintelligible  because  of  the  imperfect  movements 
of  the  tongue.  Swallowing  was  difficult  and  the  muscles 
of  the  throat  weak.  The  jaw  jerk  was  active.  The  muscles 
of  the  arms  and  shoulders  were  in  continual  fibrillation; 
movements,  however,  were  possible,  except  in  the  hands, 
where  all  motion  was  imperfect.  The  muscles  showed 
distinct  atrophy.  The  arm  reflexes  were  active,  especially 
at  the  elbow.  There  was  no  disorder  of  sensation.  The  legs 
were  practically  uninvolved;  the  knee  jerks  were  active; 
there  was  no  clonus;  normal  plantar  and  Achilles  reflex; 
there  was  no  Romberg  sign.  Sensation  of  the  feet  and  legs 
was  normal.  The  heart  showed  no  murmurs  or  enlargement; 
the  pulse  was  92;   pressure,  120. 

Diagnosis.  This  patient  is  suffering  from  Progressive 
Bulbar  Paralysis  of  the  spastic  type  (amyotrophic  bulbar  pa- 
ralysis). The  identity  of  this  condition  with  progressive  mus- 
cular atrophy  of  the  spastic  type  (amyotrophic  lateral  sclero- 
sis) is  evident.  The  process  in  this  case  invades  primarily  the 
bulbar  nuclei  or  affects  them  simultaneously  with  the  cells 
of  the  cervical  ventral  horns.  The  symptom-complex  is, 
therefore,  determined  solely  by  the  point  at  which  the  de- 


224  CASE   HISTORIES    IN    NEUROLOGY. 

generation  of  the  nene  cells  begins.  If  the  lesion  be  confined 
to  the  bulbar  nuclei,  the  resultant  condition  is  a  simple  pro- 
gressive bulbar  paralysis.  If,  on  the  other  hand,  as  In  this 
case,  bulbar  nuclei  and  the  cer\acal  cord  be  simultaneously 
or  progressively  involved,  a  combination  results  leading  to  a 
progressive  muscular  atrophy  of  the  spinal  type,  associated 
with  bulbar  paralysis.  The  pathological  anatomy  of  progres- 
sive bulbar  paralysis  Is  similar  to  that  of  the  spinal  type, 
namely,  primary  disintegration  of  peripheral  motor  neurones 
and,  if  associated  with  degeneration  of  the  pyramidal  tracts, 
giving  rise  to  the  spastic  variety  of  the  disease. 

Prognosis.  The  outcome  Is  Invariably  fatal,  death  usually 
resulting  from  paralysis  of  deglutition  and  consequent  starva- 
tion. 

Treatment.  It  is  possible  that  the  disease  may  be  checked 
somewhat  in  its  course  by  the  liberal  administration  of  strych- 
nia. It  should  be  given  to  the  point  of  toleration.  In  this 
case,  lead  poisoning  may  have  been  an  exciting  cause.  The 
withdrawal  of  lead,  however,  at  the  stage  of  the  disease  when 
the  patient  was  seen,  although  desirable,  would  not  materially 
affect  the  progress  of  the  degeneration.  Solid  food  and  liquids 
are  both  swallowed  with  difficulty  in  paralysis  of  the  throat 
muscles  and  recourse  must  therefore  be  had  to  seml-sollds, 
such  as  custards  and  the  like.  In  the  later  stages  tube  feeding 
is  possible  but  of  doubtful  utility  since  It  merely  prolongs  a 
pitiable  condition  of  inevitably  fatal  outcome.  This  is  also 
true  of  rectal  feeding. 


BRAIN.  225 

Case  85.  C,  a  woman  of  sixty-two,  had  been  well  up  to  the 
preceding  summer.  During  the  succeeding  winter  she  had 
suffered  somewhat  from  nausea,  vertigo,  and  a  sense  of  falling 
backward  when  she  lay  down.  Her  appetite  was,  however, 
not  affected.  For  a  year  past,  a  peculiarity  of  gait  had  been 
noticed,  marked  by  uncertainty  and  swaying.  Her  vertigo 
was  of  the  type  in  which  external  objects  seemed  to  move. 
She  was  seen  by  an  aurist,  who  regarded  the  condition  as 
a  Meniere's  complex.  The  ear  was  blown  out  and  she  was 
distinctly  helped.  Her  hearing  improved  for  a  time,  the  ver- 
tigo was  better  and  the  nausea  disappeared.  The  right  ear 
became  deaf,  but  she  still  had  fairly  good  hearing  in  her  left. 
Later,  the  gait  grew  very  much  worse,  with  constant  sensation 
of  falling  backward.  She  did  not,  however,  lose  consciousness 
and  at  no  time  had  convulsions  or  distinct  loss  of  speech. 
She  slept  well.  Of  late  she  had  had  some  difficulty  in  swallow- 
ing and  liquids  were  likely  to  regurgitate. 

On  physical  examination  the  pupils  were  in  no  way  remark- 
able; on  attempting  to  fix  the  eyes  laterally,  nystagmus 
developed,  and  a  certain  lack  of  agility  in  movement  became 
apparent.  The  fundus  was  not  sharply  seen  on  the  right 
but  the  vessels  were  perfectly  clear  on  the  left.  The  sensation 
of  the  face  was  normal ;  there  was  no  disturbance  in  the  motor 
portion  of  the  fifth  nerve;  a  slight  right  facial  paralysis  was 
evident;  winking  was  imperfect  on  that  side,  although,  in 
general,  voluntary  movements  were  preserved.  She  com- 
plained that  her  food  tasted  bitter.  Speech  was  slightly  thick, 
but  movements  of  the  tongue  were  apparently  free  and  the 
muscles  were  not  definitely  atrophied.  There  was  no  paraly- 
sis of  the  palate,  but  swallowing  was  occasionally  difficult, 
as  before  stated.  The  strength  of  the  arms  was  adequate; 
there  was  a  very  slight  ataxia  and  a  complaint  of  numbness 
of  the  left  hand.  The  knee  jerks  were  active;  the  plantar 
reflexes  normal;  no  clonus.  General  sensation  and  the  sense 
of  position  were  unimpaired.  There  was  much  Romberg. 
She  walked  very  unsteadily  and  with  evident  constant  fear 
of  falling.  The  heart  showed  no  abnormality  beyond  an 
accentuated  second  aortic  sound.  The  pulse  was  rather  rigid, 
84;  the  blood  pressure,  195.     In  general,  the  patient  looked 


226  CASE   HISTORIES    IN    NEUROLOGY. 

feeble,  emaciated  and  sclerotic.  The  bodily  functions  were 
satisfactory. 

The  patient  died  seven  months  later.  She  failed  slowly; 
was  obliged  to  remain  In  bed  through  loss  of  strength  for  the 
last  three  months.  For  two  months  her  speech  became  almost 
unintelligible.  Saliva  flowed  constantly  from  her  mouth  and 
she  had  much  regurgitation  of  liquids  through  the  nose.  The 
immediate  cause  of  death  was  edema  of  the  lungs. 

Diagnosis.  The  most  probable  explanation  of  the  symp- 
toms in  this  case  was  a  general  Arteriosclerosis  with  special 
localization  in  and  about  the  brain  stem.  The  aural  disturb- 
ance is  no  doubt  to  be  explained  on  the  basis  of  arterial  changes, 
and  the  final  Bulbar  Paralysis  Is  to  be  regarded  rather  as  a 
result  of  arteriosclerosis  than  as  a  primary  degeneration  of 
bulbar  nuclei  as  Illustrated  In  Case  84. 

Prognosis.  This  patient  lived  less  than  two  years  after  the 
first  onset  of  definite  symptoms.  The  length  of  life  varies 
widely  In  different  cases,  but  the  ultimate  outcome  is  fatal 
in  cases  of  gradual  onset. 

Treatment.  Small  doses  of  iodide  of  potash,  5  grains  1. 1,  d., 
were  given  in  the  hope  of  relieving  the  sclerotic  condition. 
This  treatment,  though  no  doubt  harmless,  must  be  regarded 
with  considerable  skepticism.  Other  than  that  and  the  treat- 
ment of  the  ear,  general  care  sufficed  to  render  the  last  months 
of  her  life  reasonably  comfortable. 


BRAIN.  227 

Case  86.  A.,  a  man  of  sixty- two,  leading  a  life  of  leisure, 
had  been  well  up  to  seven  years  before.  At  that  time  he  had 
an  attack  similar  to  the  one  about  to  be  described,  but  not 
so  severe,  from  which  he  recovered  completely  but  somewhat 
gradually.  He  had  thereafter  considered  himself  in  general 
well.  Four  days  before  being  seen  he  fell  from  a  ladder  and 
had  remained  in  the  house  since,  although  he  sustained  no 
material  injury.  The  following  night  he  felt  as  usual.  The 
day  before,  he  noticed,  however,  that  he  was  not  entirely 
normal  and  early  on  the  day  when  he  was  seen  he  had  "  a 
peculiar  sensation  in  the  throat,"  as  he  expressed  it,  without 
pain.  There  was  no  headache.  He  was  seen  in  a  hour  by  his 
physician,  who  noticed  a  distinct  defect  in  speech,  although 
he  was  quite  able  to  make  himself  understood.  A  few  hours 
later,  however,  he  was  unable  to  talk  at  all,  but  with  retained 
capacity  to  write  and  with  a  perfect  understanding  of  what 
was  said  to  him.    His  kidneys  had  been  normal. 

When  examined,  the  right  pupil  was  irregular  in  outline, 
dilated,  with  inadequate  light  reaction.  There  was  some  power 
of  accommodation;  the  fundus  was  not  examined.  The  ocu- 
lar movements  were  unimpeded.  There  was  slight  right 
facial  paralysis  involving  the  upper  branch  as  well  as  the 
others.  The  hearing  was  unaffected.  Swallowing  was  ac- 
complished with  difficulty  and  with  a  tendency  toward 
regurgitation.  The  tongue  was  protruded  well  in  the  median 
line  and  except  for  finer  movements  appeared  normal. 
His  speech,  however,  was  exceedingly  defective,  although  he 
was  able  to  find  his  words  and  apparently  had  no  difficulty 
whatever  in  comprehension.  He  wrote  by  preference  and  with 
perfect  correctness.  There  was  a  strong  tendency  to  laugh 
without  provocation.  The  arms  showed  excellent  strength, 
without  ataxia  or  sensory  disorder.  The  right  wrist  jerk 
was  possibly  slightly  greater  than  the  left.  The  abdominal 
reflexes  were  present.  Except  for  an  old  injury  of  the  right 
leg,  the  legs  were  normal  in  strength  and  sensation.  The  knee 
jerks  were  active,  there  was  no  clonus  and  a  slight  normal 
plantar  reaction.  The  heart  showed  no  abnormality  beyond 
a  definite  accentuation  of  the  second  aortic  sound.  The  pulse 
was   small;    the  radial    arteries   high;    the    rate,    ']2.     The 


228  CASE   HISTORIES    IN    NEUROLOGY. 

subsequent  history  of  the  case  was  immediate  and  con- 
tinued improvement,  resulting  in  an  excellent  recovery  with 
very  slight  speech  defect.  This  was  within  two  weeks  after 
the  foregoing  examination. 

Diagnosis.  The  relatively  sudden  onset  of  speech  disturb- 
ance, together  with  difficulty  in  swallowing  and  slight  pe- 
ripheral disorder  in  the  distribution  of  one  seventh  nerve, 
justifies  the  diagnosis  of  Acute  Bulbar  Paralysis.  The  speech 
defect  in  itself  was  sufficient  to  differentiate  the  condition 
from  a  true  aphasia  or  a  true  aphonia.  In  the  latter  case 
paralysis  of  the  vocal  cords  would  have  been  in  evidence, 
and  in  the  former  the  defect  of  speech  would  have  been 
characterized  either  by  a  failure  to  understand  (sensory) 
or  by  a  difficulty  in  choosing  words  to  express  ideas  (motor). 
Neither  of  these  conditions  were  present.  The  difficulty  lay 
rather  in  the  management  of  the  tongue  and  of  the  peripheral 
organs  of  speech.  The  diagnosis  of  a  lesion  of  the  oblongata, 
presumably  on  a  vascular  basis,  is  further  borne  out  by  the 
associated  difficulty  in  swallowing  (vagus-glassopharyngeal 
group)  and  the  evident  existing  arteriosclerosis. 

Prognosis.  The  outcome,  as  stated,  was  rapid  recovery. 
He  had,  however,  had  two  attacks,  the  second  more  serious 
than  the  first;  others  may  naturally  be  expected. 

Treatment.  The  treatment  consisted  in  attention  to  the 
vascular  system  through  gentle  stimulation  of  the  heart. 
In  such  conditions  over-exertion  is  to  be  definitely  prohibited. 


BRAIN.  229 

Case  87.  L.,  a  married  woman  of  forty-three,  had  had  three 
well  children  and  no  miscarriages.  For  about  a  year  she  had 
suffered  from  unusual  fatigue,  but  in  spite  of  this  considered 
herself  well.  Eight  months  before  being  seen,  she  had  waked 
in  the  morning  with  diplopia  due  to  a  sudden  internal  strabis- 
mus. She  recovered  from  this  at  the  end  of  about  five  months. 
For  the  past  three  or  four  months,  she  had  noticed,  as  she 
expressed  it,  weakness  of  different  parts  of  the  face,  especially 
on  the  left  side.  A  difficulty  in  using  her  mouth  properly 
began  about  two  months  before  she  was  seen.  This  increased 
and  for  three  weeks  she  had  not  been  able  to  eat  solid  food 
and  had  found  it  comfortable  to  support  the  lower  jaw  by 
a  bandage.  Swallowing  had  not  been  affected  and  there  was 
no  regurgitation  of  food.  She  had  had  much  paresthesia 
of  the  face,  —  hot  and  cold  sensations,  with  pain  through 
the  forehead,  face  and  occiput.  Her  head  had  felt  as  if  "  cov- 
ered with  a  cap."  In  general,  her  strength  had  decreased. 
Her  appetite,  however,  remained  satisfactory;  she  was  con- 
stipated but  not  more  so  than  ordinarily,  and  restless  at 
night. 

Examination  showed  a  well  developed  and  nourished 
woman.  Her  pupils  were  equal,  normal  in  outline  and  reacted 
well  to  light  and  on  accommodation.  The  sense  of  smell 
(menthol  and  cloves)  was  diminished  on  the  left  side.  Taste 
was  also  very  much  impaired  on  the  left  half  of  the  tongue 
in  the  anterior  portion  (quinine  and  sugar).  Hearing  was 
deficient  on  the  left.  A  watch  was  not  heard  when  close 
against  the  ear,  and  both  air  and  bone  conduction  were 
reduced.  The  tongue  was  protruded  slightly  to  the  right 
and  its  movements  were  imperfect  and  retarded.  The 
mouth  could  be  opened  satisfactorily  but  not  closed  with 
ordinary  strength.  There  was  also  slight  involvement  of  the 
spinal  accessory  nerve.  The  eye  movements  were  normal 
and  the  fundus  showed  no  change.  The  striking  paralysis 
to  which  special  attention  should  be  directed  was  that  of 
both  fifth  and  both  seventh  nerves.  All  the  branches  of  both 
facial  nerves  were  involved  to  such  a  degree  that  the  face 
was  wholly  expressionless,  and  practically  no  voluntary 
movements  were  possible.     The  motor  portions  of  the  fifth 


230  CASE    HISTORIES    IN    NEUROLOGY. 

ner\es  were  likewise  almost  completely  paralyzed.  There 
was  no  strength  in  the  masseters;  the  mouth  hung  open 
unless  supported,  and  lateral  movements  of  the  lower  jaw 
were  impossible.  The  sensory  loss  in  the  distribution  of 
this  nerv^e  w^as  not  conspicuous.  The  blood  showed  a  slight 
achromia  with  a  w^hite  count  of  from  eight  to  nine  thousand 
and  hemoglobin  of  seventy  per  cent.  The  urine  was  of  low 
specific  gravity  with  at  times  a  slight  trace  of  albumin  and 
many  squamous  cells,  much  detritus  and  a  few  leucocytes 
in  the  sediment.  Suddenly,  while  in  the  hospital,  she  fainted, 
and  died  the  following  afternoon  without  the  development 
of  further  symptoms.  There  had  been  during  life  no  sus- 
picion of  other  disease  than  that  relating  to  the  nervous 
system. 

Autopsy.  The  post-mortem  examination  showed  a  double 
ovarian  carcinoma  with  metastases  in  the  retroperitoneal 
glands  filling  the  pelvis.  Both  kidneys  were  riddled  with  can- 
cer. There  was  thrombosis  of  the  pelvic  glands;  complete 
occlusion  of  the  right  pulmonary  artery;  a  riding  thrombus 
in  the  foramen  ovale  and  coronary  embolus.  Macroscopic 
examination  of  the  brain  stem  showed  nothing  abnormal, 
but  microscopically  a  process  superficially  resembling  a  neuri- 
tis was  apparent  in  the  course  of  the  fifth,  and,  to  a  less  extent, 
of  the  seventh  nerves  within  the  substance  of  the  pons. 
This  apparent  inflammatory  process  was  also  evident  on  the 
surface,  constituting  a  meningitis.  The  blood  vessels  in 
these  regions  showed  an  inflammatory  reaction  in  their 
neighborhood,  largely  composed  of  lymphoid  cells.  The  pos- 
sibility of  syphilis  must  be  considered,  although  an  absolute 
demonstration  of  this  as  a  cause  of  the  lesions  cannot  be 
determined  in  view  of  the  fact  that  the  spirochete  were  not 
demonstrated.  The  resemblance  of  the  process  to  polio- 
myelitis, as  recently  observed,  is  certainly  worthy  of  mention. 
Finally,  an  actual  neuritis  of  the  cranial  nerves  is  not  to  be 
excluded  as  a  possibility. 

Diagnosis.  The  case  is  of  interest  because  of  the  fact  of 
the  very  unusual  type  of  cranial  nerve  involvement  and  also 
because  the  apparently  independent  carcinoma  had  entirely 
escaped  observation  during  life  and  had  given  rise  to  no  symp- 


BRAIN.  231 

toms  whatever  calling  the  attention  either  of  the  patient  or 
of  the  physicians  to  the  serious  condition.  Death  evidently 
resulted  from  vascular  disturbances  centering  in  the  heart. 
The  lesion  of  the  bulbar  nerves  is  difficult  to  classify.  Its 
inflammatory  character  lends  some  justification  to  the  diagno- 
sis of  a  true  neuritis  rather  than  to  a  primary  degeneration  of 
the  bulbar  nuclei,  as  supposed  during  life.  The  recovery  of 
certain  nerves  after  being  definitely  aff^ected  is  also  of  impor- 
tance in  arriving  at  a  conclusion  as  to  the  nature  of  the  lesion. 
It  is  not  probable  that  the  pelvic  carcinoma  had  any  bearing 
upon  the  cranial  nerve  disease. 

Prognosis.  If  the  process  had  extended  further,  the  pa- 
tient would  probably  have  died  through  lesions  of  the  lower 
cranial  nerves.  As  it  happened,  death  resulted  from  a 
wholly  unexpected  cause,  as  described  in  the  foregoing 
statement. 

Treatment.  Treatment  was  entirely  unavailing  and  con- 
sisted merely  in  palliative  measures.  Had  the  cancer  been 
recognized,  the  metastases  were  too  wide  to  permit  of  opera- 
tion. 


-^o- 


CASE   HISTORIES    IN    NEUROLOGY. 


Case  88.  C,  a  woman  of  twenty-seven,  married  three 
years,  had  had  one  child  under  normal  conditions  except  for 
a  slight  albuminuria.  She  was  six  and  a  half  months  preg- 
nant with  a  second  child.  Up  to  within  three  years  she  had 
never  had  a  headache  and  was,  in  general,  well  and  actively 
employed  as  a  teacher.  About  three  years  before  being  seen, 
she  began  to  have  headache,  irrespective  of  pregnancy. 
The  pain  was  occasionally  throbbing  in  character,  but  for 
the  most  part  dull.  She  had  had  no  vomiting  and  considered 
herself  well  in  other  ways.  During  the  past  year  she  had  worn 
glasses  with  benefit.  She  was  seen  April  9,  1910.  For  ten 
days  the  headache  had  been  worse,  throbbing  in  character, 
and  later  there  was  much  shooting  pain.  She  was  not  an 
imaginative  or  nervous  person  and  her  pain  was  evidently 
due  to  some  well-defined  though  obscure  cause.  Exercise 
apparently  had  made  the  head  pain  worse,  nor  in  the  past  had 
complete  rest  had  a  beneficial  effect.  She  was  most  comfort- 
able when  engaged  in  her  routine  work.  There  was  no  nephri- 
tis or  other  disturbance  of  the  kidney  function.  An  obste- 
trician assured  her  that  her  discomfort  had  nothing  to  do 
with  the  pregnancy.  A  provisional  diagnosis  of  influenza 
or  typhoid  fever  had  been  made  to  explain  her  more  acute 
illness  of  the  preceding  few  days.  Her  temperature  was 
from  100°  to  102°;  the  fundus  up  to  within  a  week  had  been 
clear;  when  seen  she  was  suffering  from  photophobia,  and 
for  a  day  or  two  had  had  excessive  vomiting. 

Examination  showed  normal  pupils  in  size,  light  reaction 
and  accommodation.  The  fields  were  not  restricted  and  the 
optic  disks  had  a  clear  outline  with  no  swelling.  Her  hearing 
was  unimpaired  and  there  were  no  other  cranial  nerve  in- 
volvements. The  arms  were  normal  as  regards  sensation 
and  motion ;  the  liver  was  not  enlarged ;  the  heart  gave  no 
murmurs;  the  pulse  was  100,  regular;  and  the  blood  pressure 
was  125.  The  legs  likewise  showed  no  abnormality.  The 
knee  jerks  were  normal,  there  was  no  Babinski,  no  clonus,  and  a 
normal  plantar  reflex.  The  sense  of  position  and  other  forms 
of  sensibility  were  unimpaired.  During  the  examination  the 
patient  vomited  material  mixed  with  bile,  but  without  extreme 
nausea.    A  blood  examination  showed  24,000  white  cells. 


BRAIN.  233 

When  seen  again  a  week  later  a  paralysis  of  a  part  of  the 
left  third  nerve  had  developed,  with  immobile  pupil.  The 
vomiting  had  decreased  and  the  headache  certainly  was  not 
more  severe  than  it  had  been.  The  temperature  had  remained 
elevated  but  not  reaching  above  102°.  The  pulse  had  been 
continually  rising  and  the  respiration  becoming  more  rapid. 
For  several  days  she  had  been  mentally  confused. 

Examination  at  this  time  showed  considerable  mental 
disturbance.  She  talked  vaguely  and  incoherently  and  gave 
evidence  of  occasional  hallucinations  of  sight.  She  appar- 
ently was  not  in  great  pain.  The  left  pupil  was  larger  than 
the  right  and  gave  no  reaction  to  light.  There  was  slight 
reaction  on  the  right.  The  fundus  was  absolutely  clear  on 
both  sides  and  the  disks  were  pale.  There  was  paresis  of  the 
third  nerve  on  the  left,  sparing  the  internal  rectus.  There 
was  also  slight  paresis  of  the  right  external  rectus  (sixth 
nerve)  and  of  the  right  facial  nerve.  The  other  cranial  nerves 
were  uninvaded. 

The  heart  was  excited,  the  pulse  from  132  to  136,  the 
pressure  120.  There  was  no  neck  rigidity;  neither  knee 
jerks  nor  arm  jerks  could  be  obtained ;  there  was  no  Babinski 
and  very  slight  plantar  reflex.  The  temperature  was  102° 
or  more.  She  seemed  extremely  ill,  and  no  hope  was  held  out 
for  her  recovery.  No  lumbar  puncture  was  made.  She  died 
April  18  after  an  acute  illness  of  about  three  weeks  but  with 
evidence  of  an  underlying  disturbance  extending  back  for 
three  years. 

The  autopsy  revealed  Tuberculous  Meningitis  of  an  unusual 
type  as  the  cause  of  death.  Lesions  outside  the  nerv^ous 
system  were  not  significant.  In  addition  to  the  meningitis, 
there  was  a  considerable  degree  of  encephalitis  with  general- 
ized edema  of  the  brain  leading  to  pressure  which  no  doubt 
in  part  explained  the  involvement  of  the  ocular  nerv^es. 
The  pressure  was,  however,  not  sufficiently  long  continued 
or  severe  to  produce  choking  of  the  optic  disks. 

Diagnosis.  The  diagnosis  was  not  definitely  made  during 
life  although  a  tuberculous  process  seemed  the  most  probable 
explanation  of  the  somewhat  unusual  symptoms.  The 
fact  that  the  disease  occurred  in  an  adult  previously  entirely 


234  CASE   HISTORIES    IN    NEUROLOGY. 

well  rendered  a  definite  decision  still  more  difficult.  Had  a 
lumbar  puncture  been  made,  it  is  probable  the  character 
of  the  fluid  would  have  determined  the  diagnosis.  It  would, 
however,  have  a^•ailed  nothing  by  way  of  treatment.  The 
existence  of  a  continual  temperature  otherwise  unexplained 
should  always  lead  to  the  suspicion  of  tuberculosis  and  may 
with  a  fair  degree  of  certainty  exclude  cerebral  tumor  as  a 
cause  of  symptoms.  (See  Case  78.)  A  further  difficulty 
lay  in  the  fact  that  there  was  no  clinical  evidence  of  tuber- 
culosis elsewhere  in  the  body,  although  it  was  shown  to  exist 
in  insignificant  degree  by  the  autopsy. 

Prognosis.  The  outcome  of  tuberculous  meningitis  is 
from  a  practical  standpoint  to  be  regarded  as  always  fatal, 
although  certain  evidence  is  accumulating  to  show  that  in  rare 
instances  recovery  may  take  place. 

Treatment.  Treatment  was  naturally  wholly  unavailing 
in  checking  the  progress  of  the  disease.  The  extreme  rest- 
lessness during  the  last  few  days  of  her  life  were  in  a  measure 
controlled  by  the  coal-tar  drugs  and  by  opium  preparations. 


BRAIN.  235 

Case  89.  A.,  a  man  of  twenty-seven,  was  infected  with 
syphilis,  and  a  chancre  appeared  about  the  middle  of  January, 
1903.  The  sore  was  at  first  treated  locally,  but  he  was  later 
given  mercury  internally  and  was  apparently  well  until 
about  six  weeks  before  being  seen,  on  June  15  of  the  same  year. 
He  then  began  to  have  headaches,  chiefly  at  night,  but  was  able 
to  keep  on  with  his  work.  At  the  end  of  two  weeks  he  had  a 
period  of  excessive  vomiting,  with  pain  over  his  right  eye  and 
temple,  and  suffered  greatly  at  night.  He  had  had  diplopia 
with  blurring  of  vision  for  about  a  month. 

Examination  showed  widely  dilated  pupils  with  a  rather 
slow  light  and  accommodative  response.  Vision  was  poor 
and  there  was  a  marked  double  choked  disk.  There  was  in- 
ternal strabismus  due  to  involvement  of  both  sixth  nerves; 
one  seventh  nerve  was  also  slightly  paretic.  The  tongue  was 
protruded  to  one  side.  There  was  no  paralysis  of  arms  or  legs. 
The  knee  jerks  were  normal;  the  front  tap  present  in  both; 
no  Babinski  response.  There  was  also  no  discoverable  alter- 
ation in  sensibility.     The  heart  was  normal;    the  pulse,  92. 

Treatment  was  at  once  begun,  with  immediate  improvement 
in  all  the  symptoms.  He  was  vigorously  treated  for  a  period 
of  nearly  two  years,  when  he  passed  from  observation.  At 
the  end  of  that  time  he  was  practically  well.  The  headache 
disappeared;  the  diplopia  no  longer  annoyed  him;  vision 
greatly  improved  and  the  choked  disk  entirely  disappeared, 
leaving  only  slight  evidence  of  connective  tissue  change 
along  the  vessels.  He  was  able  to  return  to  his  work,  which 
required  good  vision. 

Diagnosis.  The  clear  history  of  infection  and  the  subse- 
quent symptoms  point  unquestionably  to  Cerebral  Syphilis 
as  the  diagnosis  in  this  case  quite  apart  from  the  striking 
effect  of  treatment.  The  headache,  chiefly  nocturnal,  gastric 
disturbance,  choked  disk,  palsy  of  ocular  nerves  and  general 
prostration  are  characteristic  of  a  common  type  of  syphilis 
of  the  central  nervous  system,  due  essentially  to  lesions  at 
the  base  of  the  brain.  The  choked  disk  in  these  cases  is  not 
altogether  easy  to  explain  on  the  basis  of  general  intracranial 
pressure  now  generally  regarded  as  its  cause ;  it  is  more  proba- 
ble in  these  cases  that  the  pressure  is  locally  exerted. 


236  CASE   HISTORIES    IN   NEUROLOGY. 

Prognosis.  If  taken  early  and  treated  actively  cerebral 
syphilis  of  this  type  is  remediable.  As  already  stated,  this 
patient  recovered  in  an  entirely  satisfactory  way;  if,  however, 
the  process  had  been  allowed  to  reach  the  destructive  stage, 
very  much  less  could  have  been  accomplished.  The  important 
element  in  prognosis  is,  therefore,  immediate  and  adequate 
treatment. 

Treatment.  Mercury  by  inunction  (Ung.  Hydrarg.)  was 
given  at  once.  It  should  be  applied  once  daily  in  dram 
doses  until  an  ounce  of  the  ointment  is  used,  unless  the  patient 
is  mercurialized  by  that  amount.  In  that  event  it  may  be 
rubbed  in  every  other  day.  Mercury  in  this  or  some  other 
form  should  be  given,  with  intermissions,  over  a  period  of 
several  months,  and  thereafter  twice  a  year  for  an  indefinite 
period.  Iodide  of  potash  was  given  in  this  case  up  to  90 
grains  t.  i.  d.,  either  in  the  intervals  of,  or  alternating  with,  the 
mercury  treatment.  It  is  rarely  necessary  to  give  more  than 
this  amount  of  iodide,  and  less  is  usually  sufficient,  especially 
if  combined  with  mercury.  It  is  well  also  to  continue  the 
iodide,  at  intervals,  after  the  visible  symptoms  have  disap- 
peared. It  is  as  yet  too  early  to  state  the  effect  of  ' '  salvarsan  " 
in  cases  of  this  sort,  but  sufficient  experience  has  accumu- 
lated to  justify  its  use.  It  had  not  been  discovered  when  this 
case  was  seen. 


BRAIN.  237 

Case  90.  S.,  a  young  man  of  nineteen,  while  playing 
baseball,  was  struck  by  a  pitched  ball  in  the  left  occipital 
region  of  the  head.  He  dropped  at  once  to  the  ground 
but  was  not  unconscious.  He  got  up  in  a  dazed  fashion  and 
wished  to  go  on  playing.  He  was  able  to  walk  to  a  carriage, 
but  when  put  to  bed  was  still  in  a  confused  state.  He  talked 
very  little,  vomited  during  the  night,  was  restless  and  in 
pain.  In  the  morning  he  fell  asleep  and  was  drowsy  the  follow- 
ing day.  He  did  not  seem  to  grow  worse.  He  still  talked 
very  little  and  misused  words,  choosing  wrong  words  to  ex- 
press his  ideas.  He  was,  however,  conscious  of  his  mistakes. 
When  seen  by  a  physician,  his  pulse  was  48,  regular,  not  of 
apparent  high  tension ;  later  it  became  somewhat  arythmic. 
The  following  day  he  was  taken  to  a  hospital. 

When  examined  there  the  following  conditions  were  found. 
The  pupils  were  equal  and  reacted  normally.  The  day  before 
he  had  had  some  diplopia,  but  there  was  no  visible  paralysis 
of  the  ocular  muscles.  The  temperature  was  99°.  He  was 
evidently  in  a  good  deal  of  pain,  referred  particularly  to  the 
point  where  he  had  been  struck.  There  was,  however,  no 
sign  of  fracture  and  no  discharge  from  the  ear.  He  was 
conscious;  his  mind  was  perfectly  clear  and  he  was  disturbed 
somewhat  by  the  examination.  In  speaking  he  still  mixed  his 
words,  but  for  the  most  part  easily  made  himself  understood. 
He  was  inclined  to  yawn  continually  and  to  fall  ofif  into  a  doze. 
Further  examination  showed  a  certain  apathy  and  slowness 
but  otherwise  no  mental  disturbance.  The  fundus  was 
possibly  slightly  hazy  but  there  was  no  swelling  or  hemorrhage 
in  either  eye.  Hearing  was  normal;  there  was  no  facial 
paralysis  and  no  limitation  in  the  movements  of  the  eyes; 
the  heart  showed  no  murmurs;  the  pulse  was  52;  the  pres- 
sure, 135.  The  arms  showed  nothing  abnormal  as  regards 
strength,  sensation  or  reflexes.  There  were  slight  abdominal 
reflexes.  The  knee  jerks  were  normal;  there  was  no  clonus; 
the  Achilles  reaction  was  not  obtained;  the  plantar  reflex 
was  normal.  Sensation  of  the  feet,  including  sense  of  position, 
was  unimpaired.  There  was,  and  had  been,  no  sphincter 
disturbance.  In  general,  therefore,  the  physical  examination 
was  essentially  negative  except  for  some  slowness  in  mental 


238  CASE    HISTORIES    IN    NEUROLOGY. 

processes,  a  slow  pulse  and  a  slight  speech  defect.  Improve- 
ment began  at  once  and  continued  uneventfully. 

He  was  not  seen  again  until  about  four  months  later.  He 
then  stated  that  some  slight  difficulty  in  speech  persisted 
for  nearly  two  months  after  the  accident,  with  continued 
difficulty  in  finding  the  right  words.  He  had  also  had  vertigo, 
especially  on  quickly  turning  his  head  or  suddenly  rising  to 
an  erect  position.  There  had  likewise  been  more  or  less  pain 
at  the  back  of  the  head  when  using  his  brain  or  eyes.  Sleep 
had  not  been  quite  so  good  as  formerly,  and  he  had  grown 
somewhat  nervous  about  himself  and  about  his  possible  future. 
He  had  difficulty  in  applying  himself  to  his  work  and  had 
found  it  difficult  to  play  active  games,  such  as  tennis.  Physi- 
cal examination  at  this  time  revealed  nothing  abnormal. 
The  pulse  was  72  and  the  blood  pressure  135,  exactly  as  two 
or  three  days  after  the  blow. 

Diagnosis.  This  patient  suffered  a  relatively  mild  Concus- 
sion or  slight  Contusion  of  the  brain,  leading  to  a  certain 
degree  of  cerebral  edema,  not,  however,  reaching  a  point 
at  which  life  was  in  any  way  threatened.  The  symptoms  in 
cases  of  this  sort  are  doubtless  due  to  the  edema  of  the  brain 
consequent  upon  the  blow  rather  than  to  the  direct  effect 
of  the  injury  itself. 

Prognosis.  The  prognosis  in  this  case  was  given  as  entirely 
favorable,  which  the  event  justified  in  great  measure.  A 
certain  defect,  however,  persisted  for  a  long  period,  character- 
ized by  rather  general  nervous  disturbances,  which  had  proved 
a  distinct  handicap.  Under  proper  conditions,  recovery 
should  ultimately  be  complete.  In  general,  a  guarded  prog- 
nosis should  be  given  immediately  after  an  accident  to  the 
head,  on  the  ground  that  the  final  effect  depends  largely  upon 
the  degree  of  edema  induced  and  this  can  never  be  definitely 
determined  until  several  days  at  least  have  elapsed.  If  the 
tendency  from  the  first  is  toward  improvement  and  at  the 
end  of  the  third  or  fourth  day  there  has  been  no  increase 
of  mental  apathy,  a  favorable  prognosis  may  be  given. 
It  should  be  remembered  that  it  takes  often  several  days  for 
the  edema  to  reach  its  height  and  that  the  interval  immedi- 
ately after  the  accident  may  show  relatively  normal  condi- 


BRAIN.  239 

tions.     An  increase  of  stupor  is,  therefore,  always  a  sign  of 
danger. 

Treatment.  Absolute  quiet,  a  low  diet,  a  darkened  room 
and  careful  nursing  are  the  requisites  of  treatment  in  the  early 
stages.  Operation  in  the  absence  of  fracture  is  rarely  justified 
except  in  those  cases  where  the  pressure  is  evidently  increasing 
to  an  alarming  degree.  Lumbar  puncture  is  a  method  of 
doubtful  utility,  since  the  brain  substance  itself  is  edematous. 
Should  operation  be  undertaken,  a  generous  opening  in  the 
skull  should  be  made.  In  this  case,  no  active  treatment  was 
necessary. 


240  'case  histories  in  neurology. 

Case  91.  E.,  a  boy  of  ten,  on  November  7,  1909,  was  struck 
by  an  automobile.  The  main  injury  was  in  the  left  parietal 
region  of  the  skull,  back  of  the  ear.  There  were  no  immediate 
convulsions  or  vomiting  and  he  was  not  deeply  unconscious, 
even  immediately  after  the  receipt  of  the  blow.  He  was  seen 
at  once  by  a  physician,  who  removed  splintered  bone,  finding 
the  dura  lacerated  and  the  brain  substance  oozing  from  the 
wound.  There  was  no  extensive  hemorrhage,  but  several 
vessels  were  tied  in  the  course  of  the  operation.  At  first 
the  temperature  was  100°,  the  pulse  62  and  the  respirations  20. 
On  the  third  day,  the  temperature  rose  to  102.8°.  He  was  seen 
and  examined  the  fourth  day  after  the  accident.  He  had  at 
that  time  not  recovered  consciousness,  but  he  was  able  to 
swallow  and  ate  with  apparent  relish.  He  had  not  spoken 
and  there  was  no  conspicuous  paralysis. 

The  patient  was  lying  on  his  right  side  and  there  was  a  large 
ecchymosis  about  the  left  eye.  A  surgical  wound  two  to 
three  inches  in  length  somewhat  loosely  stitched  appeared 
in  the  left  parietal  region.  Between  the  stitches  of  this  in- 
cision, normal,  apparently  uninfected  brain  substance  was 
oozing.  Since  the  day  before  there  had  been  at  first  intermit- 
tent and  later  more  constant  spasmodic  movements  of  the 
right  side  of  the  face  and  the  right  arm,  especially  of  the  hand. 
During  the  examination,  there  was  constant  twitching  of 'the 
right  facial  muscles,  particularly  noticeable  about  the  mouth. 
There  was  also  constant  spasm  of  the  right  arm.  The  eyes 
were  turned  strongly  toward  the  right  (conjugate  deviation) 
with  extreme  nystagmus.  Later,  during  the  same  examination, 
there  was  a  temporary  cessation  of  the  spasmodic  movements; 
the  eyes  turned  in  the  other  direction  and  the  nystagmus 
also  ceased.  The  pupils  gave  a  fair  light  reaction.  Except 
as  stated  the  right  arm  was  not  moved.  Knee  jerks  were 
both  very  active,  the  right  slightly  more  so  than  the  left; 
there  was  a  definite  Babinski  response  on  the  right,  doubtful 
on  the  left;  Achilles  reaction  was  present  on  the  right,  not 
obtained  on  the  other  side.  There  was  evident  paresis  of  the 
right  leg,  but  on  pricking  it  was  drawn  away.  The  body 
showed  a  number  of  bruises.  The  patient  was  stuporous 
but  could  be  roused  though  not  to  the  point  of  speaking. 


BRAIN.  241 

In  spite  of  the  very  serious  injury  to  the  brain  and  to  the  loss 
of  a  part  of  its  substance,  the  boy  made  an  uninterrupted 
recovery.  A  report,  February  23,  1910,  was  to  the  effect 
that  he  had  gained  in  weight  and  that  he  felt  as  well  and  strong 
as  ever.  His  father  thought  that  his  speech  was  slightly 
affected  still.  In  general,  however,  the  boy  was  well  and  with- 
out motor  defect. 

Diagnosis.  In  this  case  there  was  fracture  of  the  parietal 
bone  on  the  left  side,  with  laceration  of  the  dura  and  brain. 
The  spasmodic  movements  are  to  be  explained  either  by 
contre  coup  injuring  the  motor  region  or  more  probably  by  the 
general  Concussion  and  Contusion  which  the  entire  brain 
received,  with  consequent  Edema.  The  spasmodic  character 
of  the  motor  disturbance  pointed  to  an  irritative  rather  than 
a  destructive  lesion,  as  did  also  the  deviation  of  the  eyes. 
The  fact  that  he  recovered  without  motor  loss  bore  out  this 
assumption.  The  trifling  persistent  speech  defect  is  probably 
to  be  explained  by  a  slight  invasion  of  the  speech  area  by  the 
traumatism.  The  area  invaded  was,  however,  not  concerned 
primarily  with  important  objective  functions.  Hence,  a 
violent  injury  there  would  be  far  less  productive  of  conspicu- 
ous results  than  in  certain  other  portions  of  the  brain. 

Prognosis.  The  case  demonstrates  that  if  sepsis  can  be 
avoided,  extremely  severe  injuries  to  the  brain  may  not 
prove  fatal.  This  is  particularly  true  in  young  children. 
The  loss  even  of  considerable  amounts  of  brain  susbtance 
is  not  permanently  deleterious,  provided  a  silent  area  of  the 
brain  is  invaded,  as  in  this  instance. 

Treatment.  The  treatment  consisted  in  careful  surgical 
asepsis  and  the  administration  of  urotropin  in  doses  of  fifteen 
to  twenty-five  grains  a  day,  as  a  prophylactic  measure. 


SECTION  IV. 

CONDITIONS  OF  VAGUE  OR  UNDETERMINED 
PATHOLOGICAL   BASIS. 

The  following  cases,  classified  as  "  Conditions  of  Vague  or 
Undetermined  Pathological  Basis,"  constitute  a  large  group 
in  which  investigation  is  rapidly  progressing  toward  more 
accurate  knowledge.  It  appears  probable  that  many  of  these 
conditions  will  soon  definitely  be  placed  in  the  category  of 
diseases  with  a  fixed  underlying  pathological  anatomy.  In 
the  meantime,  they  may  be  considered  as  on  the  border  line 
between  the  so-called  organic  or  structural  diseases  and 
those  which  are  clearly  of  psychogenic  origin.  The  cases  in 
this  section  are,  therefore,  to  be  regarded  as  in  that  large 
provisional  class  sometimes  spoken  of  as  the  neuroses,  since 
their  exact  anatomical  basis  is  as  yet  uncertain.  It  is  im- 
portant that  they  be  distinguished,  on  the  one  hand,  from 
those  conditions  of  which  illustrations  are  given  in  the  fore- 
going sections,  wherein  there  is  no  further  doubt  of  the 
anatomical  basis,  and,  on  the  other  hand,  from  those  in  which 
it  is  equally  evident  that  the  mental  factor  is  predominant 
both  in  etiology  and  pathology. 

Case  92.  H.,  a  man  of  fifty-four,  had  noticed  tremor  of  the 
left  hand  for  three  or  four  years  without  the  slightest  exten- 
sion to  the  right  hand  or  to  other  parts  of  the  body.  With 
this  had  come  on  difficulty  in  free  movement.  He  had  no 
pain  excepting  in  the  region  of  the  heart,  and  no  headache; 
his  appetite  was  good,  his  bowels  constipated,  and  he  was 
obliged  to  get  up  once  or  twice  at  night  to  pass  urine.  His 
sleep  was  imperfect,  but  he  had  no  other  special  concern 
than  the  tremor  and  the  general  slowness  of  movement. 
He  had  also  noticed,  as  a  special  annoyance,  a  tendency 
to  laugh  without  cause. 

During  the  examination,  he  continually  laughed  uproari- 
ously and  occasionally  wept,  entirely  without  cause.      The 

243 


244  CASE    HISTORIES    IN    NEUROLOGY. 

most  trifling  matter,  he  stated,  would  bring  about  this  emo- 
tional outbreak,  laughter  being  much  more  easily  aroused 
than  weeping.  When  asked  a  perfectly  simple  question, 
he  answered,  "  Yes,  sir,"  followed  by  a  period  of  uncontrolled 
laughter.  The  pupils  were  normal,  the  right  slightly  smaller 
than  the  left;  hearing  was  adequate;  there  was  no  palsy  of 
the  tongue  or  of  deglutition,  and  in  general  the  cranial  nerves 
were  free  from  involvement  except  for  an  unassociated 
blepharospasm.  The  face  was  without  tremor.  The  arm 
reflexes  were  normal  and  there  was  no  sensory  loss.  When 
at  rest,  the  left  hand  was  in  a  continuous  state  of  tremor, 
easily  checked  by  movement.  The  legs  showed  no  abnor- 
mality. The  heart  was  without  murmurs,  the  pressure  220, 
the  pulse  100,  of  fair  regularity.  A  urinary  examination 
showed  the  specific  gravity  to  be  1,015  with  no  albumin. 
As  he  walked  the  body  was  bent  forward  with  an  apparent 
constant  tendency  to  fall;  movements  were  awkwardly 
performed  and  evidently  with  an  effort.  His  face  was  ex- 
pressionless and  the  speech  very  slow  and  monotonous 
but  not  otherwise  defective. 

Diagnosis.  This  is  an  unmistakable  case  of  Paralysis 
Agitans  (Parkinson's  disease)  as  shown  by  the  combination 
of  general  muscular  rigidity,  monotonous  speech  and  tremor, 
together  with  a  characteristic  propulsive  manner  of  walking 
and  an  expressionless  face  with  perfectly  retained  intelligence. 
The  diagnosis  may  often  be  made  in  the  absence  of  tremor; 
in  this  instance  involuntary  movements  were  limited  to  the 
left  hand,  although  the  disease  was  well  advanced.  The  char- 
acteristic of  this  tremor  as  contrasted  with  that  of  multiple 
sclerosis  is  that  it  persists  during  rest  and  ceases  temporarily 
on  active  movement  toward  an  intended  end.  The  tremor, 
or  more  properly  ataxia,  of  multiple  sclerosis  is  brought  out 
only  on  intended  movement.  (See  Cases  49,  50.)  In  spite, 
however,  of  the  very  marked  dissimilarity  of  the  two  forms 
of  tremor,  in  certain  stages  confusion  may  arise.  The  most 
important  diagnostic  feature  of  paralysis  agitans  is  the  mus- 
cular rigidity,  upon  which,  in  fact,  the  other  signs  and  symp- 
toms, including  the  speech  defect,  depend.  The  disease  may 
be   mistaken    for   myxedema   when    the    tremor   is    lacking. 


CONDITIONS   OF   VAGUE    PATHOLOGY.  245 

but  on  careful  examination  this  mistake  should  not  occur, 
particularly  after  a  trial  of  thyroid  medication.  The  forced 
laughter  in  the  foregoing  case  is  a  chance  accompaniment 
of  paralysis  agitans,  often  very  strikingly  developed  in  certain 
lesions  of  the  bulb.  The  high  blood  pressure  indicates  the 
probability  of  a  coincident  nephritis. 

Prognosis.  The  affection  is  very  slowly  progressive  and 
ultimately  fatal,  usually  through  lowered  resistance  and  the 
final  invasion  of  intercurrent  disease.  The  duration  is  from 
five  to  twenty  years. 

Treatment.  It  is  unwise  to  attempt  too  much  in  the  treat- 
ment of  paralysis  agitans.  Fluid  extract  of  hyoscyamus  was 
given  in  this  case  in  doses  of  from  5  to  lo  drops  three  times 
a  day.  The  result  was  not  appreciable.  A  bromide  prepara- 
tion, 10  grains  of  the  sodium  salt,  was  also  given,  together 
with  cascara  sagrada.  More  important  is  regulation  of  work, 
avoidance  of  undue  excitement  and  general  hygiene.  In 
spite  of  all  that  may  be  done,  the  disease  is  hopelessly  pro- 
gressive. 


246  CASE    HISTORIES    IN    NEUROLOGY. 

Case  93.  I.,  a  boy  of  twelve,  had  an  attack  of  scarlet  fever 
In  February,  1907,  from  which  he  recovered  satisfactorily 
without  an  accompanying  nephritis.  He  had  previously  had 
measles,  whooping  cough  and  tonsillitis.  In  general  he  had 
always  been  well  and  strong.  There  was  no  history  whatever 
of  rheumatism.  Four  weeks  before  being  seen,  on  May  31, 
1907,  twitching  of  the  right  hand  developed,  but  on  inquiry 
it  transpired  that  there  had  also  been  movements  of  the  nose 
and  upper  lip,  with  raising  of  the  shoulder.  There  were  also 
in^-oluntary  movements  of  the  right  leg  which  the  patient 
thought  had  begun  after  spraining  his  ankle.  His  appetite 
and  sleep  were  satisfactory  and  his  bowels  regular  in  action. 
He  had  been  accustomed  to  eat  bread,  butter,  eggs  and  milk. 
He  was,  however,  addicted  to  candy  and  drank  tea  to  some 
extent. 

Examination  showed  that  the  involuntary  movements  were 
confined  to  the  right  side.  He  walked  badly,  striking  his  left 
foot  on  the  floor  in  an  incoordinate  fashion.  These  move- 
ments were  not  simple  repetitions,  but  were  irregular  in  char- 
acter. The  pupils  gave  a  good  light  reaction.  The  heart 
sounds  were  normal,  the  pulse  100,  and  of  good  rhythm. 
The  knee  jerks  were  slight. 

Diagnosis.  When  this  patient  was  seen,  he  was  undoubt- 
edly suffering  from  Chorea,  limited  to  one  side.  It  is,  however, 
doubtful  whether  the  earlier  movements  of  the  face  and 
shoulder  belong  in  the  same  category.  From  a  diagnostic 
standpoint,  the  case  is  of  interest  because  two  distinct  though 
possibly  allied  disturbances  were  combined  in  the  same 
patient  which  are  often  confused.  Involuntary  or  semi- 
voluntary  movements  repeated  continually  in  the  same  way 
and  confined  to  certain  well-defined  groups  of  muscles  are 
more  properly  regarded  as  a  form  of  Tic  or  Habit  Spasm 
than  as  choreic.  This  was  the  type  of  disturbance  which  the 
patient  evidently  primarily  had;  the  later  and  presumably 
independent  condition  was  characterized  by  entirely  inco- 
ordinate movements,  irregularly  performed  and  not  confined 
to  any  one  set  of  muscles.  Such  irregular  movements  con- 
stitute the  motor  disturbance  of  chorea.  Although  more 
commonly  bilateral,  the  disturbance  may,  as  in  this  case,  con- 


CONDITIONS   OF   VAGUE    PATHOLOGY.  247 

fine  itself  to  one  side.  Rheumatism  is  frequent  in  the  eti- 
ology of  minor  chorea,  but  by  no  means  constant. 

Prognosis.  The  prognosis  of  the  chorea  in  this  case  is 
entirely  favorable.  It  is  in  general  a  self-limited  disease. 
The  associated  habit  spasm  is  not  self-limited,  but  may  be 
remediable  through  painstaking  training  and  re-education. 

Treatment.  Fowler's  solution  in  doses  of  from  5  to  15 
drops  should  be  given  after  each  meal,  care  being  taken  to 
stop  or  diminish  the  dose  as  soon  as  toxic  effects  manifest 
themselves.  A  good  method  of  administering  the  drug 
is  in  the  form  of  tablets  of  arsenite  of  potash,  one  one-hun- 
dredth of  a  grain  being  equal  to  approximately  a  minim  of  the 
Fowler's  solution.  It  is  important,  also,  that  rest  and  avoid- 
ance of  excitement  should  be  insisted  upon,  together  with 
a  limitation  of  the  diet  to  absolutely  simple  and  nutritious 
food,  and  scrupulous  regulation  of  the  bowels. 


248  CASE   HISTORIES    IN    NEUROLOGY. 

Case  94.  S.,  a  boy  of  eight,  for  a  year  had  developed  nod- 
ding movements  of  the  head.  For  several  weeks  past, 
twitching  of  the  legs  had  come  on,  together  with  a  curious 
habit  of  squatting  with  a  certain  twisting  of  the  legs.  These 
movements  were  repeated  in  almost  the  same  way  again  and 
again.  There  was  a  doubtful  history  of  rheumatism,  but  in 
general  the  boy  had  been  well  and  was  not  overmuch  addicted 
to  candy.  He  drank  neither  tea  nor  coffee.  He  had  been  care- 
fully brought  up  by  his  parents  in  the  country  and  naturally 
had  spent  much  of  his  time  out  of  doors.  There  was  one 
older  child  in  the  family,  who  was  well. 

The  eyes,  carefully  examined,  showed  no  abnormality. 
The  knee  jerks  were  slight  but  normal;  the  bowels  moved 
regularly  and  in  general  the  physical  condition  of  the  patient 
beyond  his  involuntary  movements  was  normal.  The  heart 
showed  no  evidence  of  endocarditis. 

When  seen  again  some  years  later  the  habits  had  been  al- 
most entirely  overcome,  although  there  were  still  some  slight 
movements,  as,  for  example,  rolling  of  the  eyes. 

Diagnosis.  This  patient  was  suffering  from  what  may 
properly  be  called  Habit  Tic.  The  mistake  is  frequently  made 
of  confusing  this  common  condition  with  chorea.  The 
essential  difference  lies  in  the  fact  that  chorea  is  constituted 
by  incoordinate  movements  in  various  groups  of  muscles, 
whereas  a  tic  of  this  type  is  characterized  by  the  repetition 
of  the  same  movements  in  certain  groups  of  muscles  and  may, 
therefore,  be  brought  into  the  category  of  habit.  The  term 
"  habit  chorea"  has  at  times,  but  inaccurately,  been  applied 
to  this  condition,  the  etiology  of  which,  admitting  an  often 
undiscovered  cause,  develops  on  the  basis  of  repetition. 

Prognosis.  In  this  case  the  outcome  was  satisfactory, 
and  it  is  not  to  be  doubted  that  the  boy  will  in  time  entirely 
overcome  his  various  habits.  In  general,  if  treatment  be 
undertaken  early,  the  prognosis  is  favorable.  Such  a  habit 
spasm  may,  however,  under  certain  circumstances,  persist 
through  life. 

Treatment.  The  treatment  is  educational.  If  the  child  is 
old  enough,  it  is  essential  to  expain  to  him  the  nature  of  the 
trouble  and  the  part  which  habit  plays  in  its  production. 


CONDITIONS    OF   VAGUE    PATHOLOGY.  249 

His  cooperation  may  thereby  be  gained  and  remarkable 
results  often  follow  certain  exercises  and  training  in  control 
in  the  effort  to  overcome  the  abnormal  movements.  As  a 
principle,  it  is  desirable  to  substitute  voluntary  for  involun- 
tary movements  in  the  hope  that  ultimately  the  power  of 
complete  control  may  be  regained.  Drugs  are  unnecessary, 
except  as  they  may  be  required  to  meet  special  indications. 


250  CASE   HISTORIES    IN    NEUROLOGY. 

Case  95.  T.,  a  man  of  thirty,  a  clerk  by  occupation,  was 
seen  in  September,  1908.  The  February  before  he  had  had 
an  unusual  sensation  at  the  back  of  his  head.  He  recognized 
the  fact  that  he  had  been  overdoing  for  several  years,  his 
work  demanding  his  Sundays  and  evenings.  He  had  had  no 
\-acatIon  for  four  years  and  he  felt  that  he  had  been  somewhat 
over-conscientious.  He  went  to  bed  tired  and  woke  equally 
so,  although  he  appeared  to  sleep  well.  He  had  no  headaches; 
his  digestion  and  appetite  were  good.  There  was  also  no 
special  source  of  worry  except  that  which  arose  in  connection 
with  his  employment.  He  was  extremely  nearsighted  and  the 
glasses  prescribed  were  presumably  not  correct.  Much  of 
his  work  consisted  in  writing,  in  doing  which  he  held  his  head 
more  or  less  to  one  side.  The  sensation  first  noticed  in  his 
neck  gradually  developed  Into  a  feeling  of  drawing  toward  the 
left  side.  This  grew  worse  until  he  was  conscious  of  abnormal 
sensations  above  the  shoulder  in  the  region  of  the  trapezius 
muscle  and  also  In  the  shoulder  blade.  The  arm  and  ulnar 
side  of  the  left  hand  were  also  somewhat  affected.  The  neck 
grew  steadily  worse,  with  a  strongly  developed  tendency 
to  turn  invariably  toward  the  left  with  the  chin  tilted  slightly 
upward.  The  shoulder,  he  thought,  was  somewhat  raised 
In  this  process.  The  difficulty  had  developed  to  such  a  degree 
that  movement  of  the  head  was  practically  constant  while 
he  was  on  his  feet,  and  especially  when  he  was  in  motion, 
either  walking  or  riding.  It  was  not  noticeably  worse  while 
he  was  at  his  work. 

The  pupils  were  equal,  with  normal  light  reaction,  and  the 
eyes  showed  a  high  degree  of  myopia.  There  was  no  palsy 
of  any  cranial  nerve;  the  heart  was  negative;  the  knee  jerks 
normal.  The  spasm  was  confined  largely  to  the  right  sterno- 
mastoid  muscle.  It  was  possible  to  overcome  this  spasm  by 
a  very  slight  pressure.  There  was  no  definite  objective  dis- 
turbance of  sensation  either  In  the  left  hand  or  In  any  other 
part  of  the  body.  The  heart  was  normal;  the  pulse  88  and 
regular.  The  physical  examination  was,  in  general,  entirely 
negative  except  for  the  muscular  spasm  described. 

Diagnosis.  This  is  a  typical  example  of  Spasmodic  Torti- 
collis, Involving  essentially  the  right  sternomastold  muscle, 


CONDITIONS    OF   VAGUE    PATHOLOGY. 


251 


the  function  of  which  is  to  turn  the  head  in  the  opposite 
direction,  very  sHghtly  tilting  the  chin  upward.  The  etiology 
is  obscure,  although  in  this  case  it  is  possible  that  the  char- 
acter of  the  patient's  work,  writing  constantly  in  one  position, 
may  have  been  an  exciting  cause. 

Prognosis.  It  has  not 
been  possible  to  follow  this 
case.  In  general,  torticollis 
of  this  type  is  a  stubborn 
affection,  occasionally  cur- 
able by  simple  means  and 
often  incurable  even  by  radi- 
cal surgical  procedures. 

Treatment.  In  this  case 
coordinative  exercises  with 
possible   subsequent   opera- 

FiG.  37.     Spasmodic  Torticollis,    Involving        tion    WCrC    adviscd.       Thc    at- 
Chiefly   the  Right   Sternomastoid   Muscle.  1111  1 

tempt  should  always  be 
made  to  re-educate  the  muscle  or  muscle  group  temporarily 
beyond  the  control  of  the  will  by  carefully  executed  active 
and  passive  movements  faithfully  carried  out.  In  this 
attempt  the  definite  relation  between  the  mental  state  of  the 
patient  and  the  spasm  should  constantly  be  borne  in  mind. 
Surgical  interference  is  justified  when  other  means  fail,  but 
when  undertaken  the  operation  should  be  radical. 


252  CASE   HISTORIES    IN    NEUROLOGY. 

Case  96.  O.,  a  married  woman  of  forty,  of  neurotic  type, 
had  been  extremely  nervous  for  a  number  of  years.  A 
diagnosis  of  Graves'  disease  had  been  made  two  years  before. 
She  had  been  treated  by  aconite  and  appHcations  of  ice  with- 
out marked  effect.  For  a  year  and  a  half  she  had  been  particu- 
larly debilitated,  the  pulse  rate  being  from  115  to  120,  asso- 
ciated with  extreme  general  nervousness.  The  eyes  had  been 
prominent  at  one  time;  she  had  not  had  much  sweating;  the 
thyroid  gland  was  considerably  but  not  excessively  enlarged. 
The  measurement  of  the  neck  was  thirteen  and  a  half  inches. 

Examination  showed  the  patient  to  be  in  a  very  excited, 
overwrought  condition;  the  pulse  when  first  taken  reaching 
to  160  and  later  falling  to  128,  and  somewhat  irregular  in 
rhythm;  the  heart  gave  no  murmurs,  but  on  the  left  side  of  the 
neck  there  was  a  loud  systolic  thrill  suggestive  of  an  aneurism. 
This  was  much  less  marked  on  the  right  side.  The  lateral 
swelling  of  the  thyroid  gland  was  not  extreme  and  there  was 
no  exophthalmos.  There  was  considerable  general  tremor, 
with  a  highly  nervous  manner. 

Hydrobromate  of  quinine  did  not  give  relief.  She  continued 
to  grow  more  disturbed  and  appeared  on  the  verge  of  a 
psychosis.  She  was  in  a  state  of  great  anxiety  regarding 
herself,  which  was  increased  by  the  undue  solicitude  of  her 
husband.  It  was  finally  decided  to  attempt  an  operation. 
A  part  of  the  gland  was  removed  surgically,  but  the  patient 
never  recovered  completely  from  the  anesthetic  and  died 
in  six  hours. 

Diagnosis.  The  patient  was  suffering  from  Exophthalmic 
Goitre  in  which  the  general  poisoning  of  the  system  was 
extreme  but  without  the  frequent  definite  physical  signs 
of  exophthalmos  and  great  swelling  of  the  thyroid  gland. 
The  characteristic  nervous  symptoms  were  particularly  well 
marked  and  the  general  resistance  of  the  patient  was  evidently 
somewhat  reduced. 

Prognosis.  Had  an  operation  not  been  undertaken  it  is 
probable  that  the  patient  would  have  continued  a  sufferer 
from  her  disease  without  marked  amelioration. 

Treatment.  Treatment  by  means  of  rest,  bromide  of  qui- 
nine and  other  measures  had  been  faithfully  carried  out  in  this 


CONDITIONS   OF   VAGUE   PATHOLOGY.  253 

case  without  result.  The  situation  justified  operation,  but, 
as  not  infrequently  happens,  the  resistance  of  the  patient  was 
such,  or  the  intoxication  resulting  from  the  partial  excision  of 
the  gland  was  so  extreme,  that  death  almost  immediately 
resulted.  Operation  in  cases  of  exophthalmic  goitre  should 
always  be  undertaken  with  caution  and  with  explanation  to 
the  family  that  the  outcome  is  more  likely  to  be  fatal  than  in 
other  operations  of  apparently  similar  menace. 


254  CASE   HISTORIES    IN    NEUROLOGY. 

Case  97.  R.,  a  married  woman  of  forty-four,  had  been 
ailing  for  four  years.  She  was  supposed  to  have  had  anemia 
in  some  form,  but  the  history  was  indefinite'  on  this  point. 
She  "  seemed  dropsical,"  was  bloated,  and  was  thought  at 
one  time  to  have  had  "  kidney  disease."  This  was,  however, 
proved  not  to  be  the  case.  After  a  journey  she  apparently 
recovered  from  her  disabilities.  She  also  suffered  from  profuse 
menstruation.  Two  years  before  being  seen  she  was  again 
in  a  debilitated  condition  and  began  to  become  deaf.  She 
had  a  cough  and  choking  sensations  and  her  speech  and  voice 
changed.  She  spoke  in  a  somewhat  scanning  manner  and 
when  tired  had  special  difficulty  in  enunciation.  Her  feet 
and  hands  were  cold  and  she  had  occasional  pain  in  the  back. 
She  found  great  difficulty  in  doing  her  work  and  was  finally 
obliged  to  give  it  up  entirely.  Her  movements  became  slow 
and  she  again  became,  as  she  expressed  it,  "  bloated." 

On  examination,  her  face  was  unnaturally  full  and  puffy 
in  appearance.  The  skin  was  dry ;  her  hair  was  falling  and 
brittle.  Sw^eating  was  diminished  except  in  the  axillae. 
The  pupils  and  fundi  were  normal  and  the  cranial  nerves 
free  of  involvement  excepting  the  auditory.  Air  and  bone 
conduction  were  defective  in  both  ears  and  she  was  distinctly 
deaf.  The  sounds  were  faint,  but  the  heart  was  otherwise 
normal ;  the  pulse  w^as  64,  the  blood  pressure  135.  The  reflexes 
were  present  and  in  no  way  remarkable;  there  were  no  mus- 
cular tremors.  The  patient  was  lethargic  in  manner  and 
slow  of  speech.    The  thyroid  gland  was  not  palpable. 

Diagnosis.  A  diagnosis  of  Myxedema  was  made  in  this 
case  from  the  dry  skin,  the  sparse  and  brittle  hair,  the  general 
tendency  toward  swelling,  especially  about  the  face,  together 
with  a  slow  pulse,  lethargic  manner  and  the  lack  of  a  palpable 
thyroid.  The  general  appearance  of  a  person  suffering  from 
myxedema  is  usually  unmistakable,  though  diiificulty  may  oc- 
casionally arise  in  differentiating  it  from  paralysis  agitans 
without  tremor.    The  therapeutic  test  is  then  decisive. 

Prognosis.  Although  the  metabolic  changes  caused  by  the 
lack  of  thyroid  secretion  are  undoubtedly  profound,  the  prog- 
nosis is  good  on  account  of  the  efficiency  of  treatment. 

Treatment.     The  deficiency  of   the  thyroid  gland  is  ade- 


CONDITIONS    OF   VAGUE    PATHOLOGY.  255 

quately  met  by  the  long-continued  administration  of  desic- 
cated sheeps'  thyroid,  beginning  with  I  to  2  grains  t.i.d. 
and  increasing  gradually  to  the  point  of  toleration.  An  aver- 
age amount  for  an  adult  is  from  3  to  5  grains  thrice 
daily.  The  treatment  must  be  continued  indefinitely,  if  the 
disease  is  to  be  held  in  check. 


256  CASE    HISTORIES    IN    NEUROLOGY. 

Case  98.  I.,  a  boy  of  fifteen,  had  been  well  up  to  twelve 
and  a  half.  Then  suddenly,  while  bathing,  he  fell  to  the  floor, 
had  a  general  convulsion,  with  frothy  saliva  at  the  mouth, 
but  did  not  bite  his  tongue  nor  have  any  involuntary  escape 
of  urine.  There  was  general  twitching  of  the  muscles  for  a 
few  minutes  (probably  not  more  than  three,  although  the 
parents  thought  ten).  He  was  unconscious  for  nearly  two 
hours.  Following  this  early  attack  he  had  had  many  others 
at  very  irregular  interv^als.  At  one  time  he  went  for  six 
months  without  a  seizure.  At  other  times  during  the  past 
two  and  a  half  years  he  had  had  attacks  at  interv^als  of  from 
two  to  four  weeks  and  for  a  certain  period  even  as  often  as 
every  other  day.  He  injured  himself  only  once,  explainable, 
no  doubt,  by  the  fact  that  he  had  a  preliminary  aura  in  the 
form  of  dizziness  and  a  sensation  as  if  he  did  not  know  whether 
his  foot  was  on  the  ground  or  in  the  air.  He  also  had  in  con- 
junction with  the  more  serious  attacks,  with  prolonged  loss 
of  consciousness,  brief  attacks  of  temporary  confusion  {petit 
mal).  In  general,  he  was  well,  the  bowel  function  was  regular, 
his  sleep  was  satisfactory  and  his  appetite  fairly  good.  He 
ate  salt  moderately  but  was  in  the  habit  of  taking  consider- 
able meat.  He  drank  tea  and  coffee,  but  not  in  excess,  and  did 
not  smoke.  He  had  not  done  well  at  school  and  was  the  least 
bright  of  the  nine  children  in  his  family.  He  ate  much  candy 
and  asserted  that  he  always  had  an  attack  soon  after  eating 
Bologna  sausages. 

Examination  showed  no  signs  of  focal  disease  of  the  brain. 
The  pupils,  knee  jerks,  heart  and  pulse  were  normal,  the 
latter  120,  owing  in  part,  no  doubt,  to  the  examination. 
There  was  no  drug  eruption,  but  the  boy  appeared  rather 
dull  mentally. 

Diagnosis.  Epilepsy  is  the  only  condition  to  be  considered 
in  this  case,  apparently  of  the  so-called  idiopathic  type.  Gen- 
eral convulsions  of  sudden  onset,  clonic  and  tonic  in  character, 
of  brief  duration,  followed  by  a  varying  period  of  stupor,  often 
with  injury  through  falling  or  through  convulsive  closure 
of  the  jaws,  are  characteristic  of  the  epileptic  seizure. 

Prognosis.  The  outcome  in  this  case  is  likely  to  be  un- 
favorable.   The  boy  is  of  somewhat  deficient  mental  develop- 


CONDITIONS    OF    VAGUE    PATHOLOGY.  257 

ment,  the  attacks  have  appeared  early  in  life,  have  occurred 
often  and  are  with  difficulty  controlled  by  treatment.  Under 
these  conditions,  the  likelihood  of  complete  cessation  of  the 
attacks  is  very  much  reduced.  Under  proper  conditions  of 
relative  isolation,  the  patient  should  lead  a  reasonably  useful 
life. 

Treatment.  A  mixture  of  sodium,  potassium  and  ammo- 
nium bromide  with  benzoate  of  soda  in  the  proportion  of  an 
ounce  of  sodium  bromide  with  half  an  ounce  each  of  potassium 
and  ammonium  bromide  and  benzoate  of  soda,  to  eight 
ounces  of  water,  is  a  good  prescription.  This  gives  15  grains 
of  the  bromides  to  each  teaspoonful.  It  should  be  given 
beginning  with  dram  doses  at  night  and  increasing  to  two, 
three  or  even  more  teaspoonfuls  in  the  course  of  the  day, 
preferably  after  meals.  Meat  of  the  finer  qualities  may  be 
allowed  once  a  day.  Common  salt  should  be  restricted.  The 
diet  should  be  nutritious,  not  too  much  of  it,  with  an  avoid- 
ance of  the  richer  and  more  highly  spiced  foods.  The 
essential  element  in  diet  is  moderation.  Under  strict  hy- 
gienic conditions  with  judicious  administration  of  bromides 
this  patient  and  persons  in  general  suffering  from  epilepsy 
are  ordinarily  greatly  benefited  but  not  cured. 


258  CASE   HISTORIES    IN    NEUROLOGY. 

Case  99.  E.,  a  woman  of  fifty-five,  had  had  attacks  of 
loss  of  consciousness  for  upwards  of  a  year,  dating,  as  she 
thought,  from  her  father's  death.  Previous  to  that  time  she 
had  been  well  and  hard-working.  The  course  of  an  ordinary 
attack  was  as  follows :  A  sudden  fall  without  warning,  except 
at  times  for  a  preliminary  period  of  yawning,  followed  by  loss 
of  consciousness  and  rigidity,  and  recovery  without  resulting 
paralysis  of  any  sort.  On  one  occasion  there  was  involuntary 
escape  of  urine.  She  also  had  had  attacks  of  similar  sort  at 
night,  as  shown  by  disarranged  bed  clothing  and  hair.  After 
the  attacks  she  felt  exhausted  for  a  varying  time.  On  one 
occasion  when  she  got  up  in  the  night  she  fell  in  a  seizure  and 
injured  herself  about  the  knees  and  ankles.  The  attacks 
described  above  had  become  increasingly  frequent  and  were 
seriously  interfering  with  her  work.  Her  general  condition 
had,  however,  remained  good;  her  sleep  and  appetite  were 
unimpaired.  She  had  passed  the  menopause  about  four  years 
before  without  noteworthy  disturbance.  She  had  of  late 
secreted  a  large  amount  of  urine,  especially  at  night,  pre- 
sumably due  to  her  general  nervous  state,  Inasmuch  as  an 
examination  showed  no  abnormality.  The  bowels  were  not 
constipated.  She  had  at  no  time  had  colic  suggestive  of  lead 
poisoning ;  there  was  no  paralysis  and  no  lead  line  on  the  gums. 

Examination  showed  normal  pupils,  with  good  light  and 
accommodative  response  and  unrestricted  fields.  The  borders 
of  the  disks  were  not  well  defined  on  the  inner  sides  but  there 
was  no  swelling.  Hearing  was  normal  and  the  cranial  nerves 
were  in  general  uninvolved.  The  knee  jerks  were  normal. 
The  heart  was  unimpaired,  the  pulse  128,  the  pressure  140. 

Under  treatment  there  was  improvement,  but  at  the  end 
of  a  week  she  again  had  two  attacks  in  one  day;  these  were, 
however,  slight  in  character,  with  very  brief  loss  of  conscious- 
ness and  without  convulsion.  A  few  days  later  she  fell  and 
injured  her  chin  and  probably  had  a  convulsion.  She  had 
a  persistent  sense  of  weakness  and  lassitude  and  grew  de- 
pressed and  emotional. 

Diagnosis.  This  condition  is  undoubtedly  Epilepsy  com- 
ing on  late  in  life  and  without  discoverable  cause.  In  general, 
epileptic  seizures  should  be  regarded  as  presumably  symp- 


CONDITIONS    OF   VAGUE    PATHOLOGY.  259 

tomatic  of  some  underlying  condition;  especially  is  this  true 
if  they  develop  after  the  third  decade.  It  not  infrequently 
happens,  however,  that  no  underlying  cause  can  be  found 
either  in  the  condition  of  the  arterial  system  or  of  the  brain, 
as  in  this  case.  Brain  tumor  should  always  be  suspected, 
and  a  possible  antecedent  syphilis  should  be  investigated. 

Prognosis.  The  outlook  for  cure  in  the  sense  of  entire 
cessation  of  the  attacks  Is  not  to  be  expected  in  this  case. 
She  has  improved  under  treatment  but  at  the  last  report 
continues  to  have  attacks. 

Treatment.  The  same  measures  in  treatment  are  useful 
as  in  cases  coming  on  early  in  life.     (See  Case  98.) 


260  CASE    HISTORIES    IN   NEUROLOGY. 

Case  100.  S.,  a  woman  of  thirty-nine,  married,  the  mother 
of  one  child,  for  upwards  of  twenty  years  had  had  occasional 
"  sick  headaches."  Her  mother  and  brother  had  similar 
headaches.  Eighteen  years  before  being  seen,  she  had  had 
twinges  of  pain  through  the  face  and  head,  varying  widely 
in  position  from  time  to  time,  and  also  in  character.  This 
pain  was  greatly  relieved  after  vomiting.  She  had  also  noticed 
during  her  attacks  of  pain  the  appearance  of  dark  falling 
objects  in  the  visual  fields.  In  general,  the  pain  was  on  one 
or  the  other  side,  not  on  both  at  the  same  time.  Her  upper 
teeth  were  false;  she  had  had  no  nasal  trouble  or  sinus 
inflammation.  She  did  not  wear  glasses.  Her  digestion  was 
imperfect.  Her  sleep  was  poor  and  she  was  in  general  un- 
nerved by  the  exigencies  of  her  life,  although  it  was  not  a  hard 
one.  It  appeared  on  further  questioning  that  her  head  pain 
was  nearly  always  associated  with  nausea,  and  that  following 
the  pain  she  was  apt  to  vomit.  In  the  severe  attacks  she  had 
a  general  exhausted  feeling,  and  her  arms  and  legs  felt  numb 
and  prickly.  There  was  also  a  sense  of  temporary  throat 
paralysis.  The  average  number  of  attacks  was  one  in  two 
weeks ;  she  was  especially  likely  to  have  one  at  her  menstrual 
period. 

Examination  show^ed  normal  pupils  and  fundi  with  un- 
constricted  fields.  There  was  a  tendency  to  external  squint 
leading  to  imperfect  convergence ;  otherwise  the  cranial  nerves 
were  normal.  The  heart  was  negative,  pulse,  80,  pressure  140. 
The  arm  and  knee  jerks  were  normal. 

In  consideration  of  the  eye  condition,  she  was  referred 
to  an  ophthalmologist,  who  reported  slight  hypermetropia 
with  insufficiency  of  convergence  to  the  amount  of  10°, 
and  also  some  vertical  deviation.  It  was,  however,  his  opinion 
that  this  amount  of  defect  presumably  had  no  bearing  upon 
her  head  disturbance. 

Diagnosis.  This  case  is  undoubtedly  one  of  Ophthalmic 
Migraine,  which  has  changed  its  form  during  the  course  of 
the  patient's  life.  In  her  early  years  she  had  had  what  she 
recognized  as  an  ordinary  sick  headache;  this  later  took  on 
the  form  of  neuralgia,  but  at  no  time  was  limited  to  any  defi- 
nite nerv'e  distribution.    The  visual  symptoms,  e  .g.,  sensation 


CONDITIONS   OF   VAGUE    PATHOLOGY.  26l 

of  falling  objects,  together  with  the  frequently  unilateral  head- 
aches associated  with  vomiting,  the  disturbance  occurring 
in  distinct  attacks,  all  point  toward  the  diagnosis  of  migraine. 
The  sensory  phenomena,  to  which  allusion  was  made  in  the 
history,  are  also  characteristic.  The  long  persistence  of  the 
disturbance  and  its  paroxysmal  character  rendered  it  un- 
likely that  eyestrain  was  an  important  factor  in  its  produc- 
tion, as  described,  for  example,  in  Case  loi.  Migraine  may 
at  times  be  mistaken  for  epilepsy  of  the  Jacksonian  type 
or  for  other  grave  cerebral  disorders.  The  combination,  how- 
ever, of  visual  disturbances,  scotomata,  or  transient  hemi- 
anopsia followed  by  headache,  especially  if  unilateral,  and 
later  by  vomiting,  form  an  unmistakable  group  of  symptoms. 
The  unusual  manifestations  of  migraine  are  frequently  some- 
what difhcult  of  diagnosis. 

Prognosis.  Migraine  is  an  exceedingly  stubborn  disturb- 
ance to  treat  with  success  owing  to  its  frequent  constitutional 
character.  The  condition  may  improve,  however,  with  ad- 
vancing years  and  not  infrequently  disappears  spontaneously, 
or  after  the  removal  of  some  apparently  trifling  source  of 
irritation. 

Treatment.  All  sources  of  peripheral  irritation  should  be 
removed.  Visual  defects  and  refractive  errors  should  be 
corrected.  The  gastro-intestinal  tract  demands  attention 
in  many  cases.  Drugs  are  essentially  unavailing  except  as  a 
means  of  relief  of  immediate  pain.  Acetanilid,  phenacetin, 
the  bromides,  aspirin,  may  be  used  with  discretion  in  dealing 
with  the  actual  attack.  A  vigorous  catharsis  is  also  frequently 
useful  in  modifying  an  attack.  The  opium  preparations 
should  be  avoided  absolutely.  During  the  attack,  if  severe, 
it  is  desirable  to  have  the  patient  go  to  bed  during  the  con- 
tinuance of  the  pain.  An  encouragement  of  vomiting  at 
times  brings  relief. 


262  CASE   HISTORIES    IN    NEUROLOGY. 

Case  loi.  N.,  a  married  woman  of  fifty-two,  had  always 
considered  herself  well,  in  spite  of  the  fact  that  she  had  xal- 
vular  disease  of  the  heart,  which,  however,  had  occasioned 
her  no  inconvenience  whatever  excepting  some  shortness  of 
breath  on  exertion.  Examination  of  the  urine  showed  no 
abnormality^  For  five  weeks  before  being  seen,  she  had  had 
occipital  and  frontal  headaches;  the  skin  of  the  scalp  was 
not  sensitive ;  there  was  no  actual  pain  on  pressure ;  she  com- 
plained of  no  other  symptoms.  She  was  not  of  ner\'ous  tem- 
perament and  the  menopause  had  been  passed  two  years 
before. 

Examination  gave  a  good  pupillary  light  reaction  with  less 
active  accommodation.  In  talking  with  her,  there  was  no 
observable  strabismus.  As  she  continued,  however,  to  fix 
her  eyes  on  a  given  point,  it  was  noticed  that  they  gradually 
diverged.  Further  investigation  showed  that  convergence 
at  close  range  was  not  possible  without  pain  and  discomfort, 
through  evident  weakness  of  the  internal  recti.  She  had  worn 
glasses  for  three  years,  presumably  prescribed  by  an  optician. 
Her  headache  had  become  most  distressing  but  had  not  been 
associated  with  vomiting.  The  knee  jerks  were  normal  and 
the  examination  otherwise  disclosed  nothing. 

Diagnosis.  In  consideration  of  the  manifest  difhculty 
in  convergence,  it  was  assumed  that  eye  strain  was.  In  this  case, 
the  cause  of  her  head  discomfort.  This  proved  to  be  the  case. 
The  localization  of  pain  due  to  eye  strain  is  usually  frontal 
or  occipital. 

Prognosis.  Proper  correction  of  the  eyes  resulted  in  com- 
plete relief  of  the  symptom  of  head  pain. 

Treatment.  She  was  referred  to  an  ophthalmologist, 
who  found  no  difficulty  In  correcting  the  muscular  error  suffi- 
ciently to  insure  a  cessation  of  the  eye  strain.  No  other  treat- 
ment was  required. 


CONDITIONS    OF   VAGUE    PATHOLOGY.  263 

Case  102.  E.,  a  woman  fifty- two  years  old,  had  noticed 
that,  about  nine  years  before,  she  had  been  obliged  to  have  her 
ring  enlarged.  Four  years  before  being  seen,  early  in  1910, 
her  hands  had  begun  to  feel  awkward  and  she  found  difificulty 
in  closing  them  completely.  There  was  slight  enlargement 
of  the  thyroid  gland.  Thyroid  extract  was  administered  with 
apparent  benefit,  so  far  as  the  condition  of  her  neck  was  con- 
cerned. This,  however,  had  at  no  time  given  her  serious 
annoyance.  Of  more  importance  was  a  gradual  enlargement 
of  the  hands.  She  had  formerly  worn  a  six  and  a  half  glove 
and  now  was  obliged  to  use  a  seven  to  a  seven  and  a  quarter. 
She  was  unable  to  get  a  large  enough  thimble  to  fit  her  finger. 
Her  feet  had  not  increased  in  size  in  proportion  to  the  hands. 
For  the  past  month  she  had  had  considerable  pain,  especially 
in  the  joints,  and  her  voice  had  become  somewhat  hoarse. 
In  general,  she  felt  well,  walked  with  pleasure  and  led  an 
active  life.  Her  bowels  were  costive  and  her  menstruation 
had  ceased.  Both  mentally  and  physically  she  had  retained 
her  former  activity.  She  had  no  headaches,  but  the  previous 
summer  she  had  had  several  attacks  of  vertigo  without  vomit- 
ing. This  was  apparently  helped  by  glasses.  She  had  had  no 
difBculty  with  her  eyes  beyond  such  as  were  incident  to 
her  age. 

Examination  showed  extremely  coarse  features,  a  broad 
nose  and  a  somewhat  oily  skin.  The  hair  was  not  remarkable. 
The  hands  were  immediately  noticeable  for  their  very  ex- 
ceptional size.  They  were  very  large  and  clumsy,  but  not 
edematous  or  unsymmetrical  in  development.  They  gave 
the  appearance  which  one  might  expect  in  a  large  man  rather 
than  in  a  somewhat  small  woman.  Without  having  been 
told,  it  would  have  been  sufficiently  evident  that  both  the 
features  and  the  extremities  had  changed  through  an  increase 
in  size  and  coarseness.  The  pupils,  fields,  fundus,  heart  and 
knee  jerks  were  normal ;  the  pulse  was  88  and  the  blood 
pressure  135. 

Diagnosis.  The  condition  in  this  case  is  unmistakably 
Acromegaly,  an  affection  presumably  dependent  upon  dis- 
order of  the  pituitary  gland.  The  affection  is  characterized, 
as  its  name  implies,  by  a  more  or  less  symmetrical  enlargement 


264  CASE   HISTORIES    IN   NEUROLOGY. 

of  the  extremities,  particularly  of  the  hands,  and  by  gen- 
eral coarsening  of  the  features,  with  other  disturbances  of 
metabolism. 

Prognosis.  The  disease  is  not  in  itself  fatal  but  is  gradually 
progressive. 

Treatment.  As  yet  no  treatment  has  been  found  effica- 
cious except  the  possible  operation  on  the  pituitary  gland  it- 
self, which  has  been  done  a  number  of  times  with  success  and 
improvement  of  symptoms.  The  operation  is  naturally  one 
of  extreme  difficulty,  owing  to  the  deep-seated  position  of  the 
gland. 


CONDITIONS   OF   VAGUE    PATHOLOGY.  265 

Case  103.  U.,  a  woman  of  thirty-six,  twelve  years  before 
being  seen  had  given  birth  to  a  baby  which  had  lived  three 
months.  She  had  had  no  children  since  and  there  was  no 
history  of  miscarriages;  in  general,  she  had  been  well  until 
within  four  months.  She  then  noticed  that  "  her  tongue  grew 
thick  so  that  she  couldn't  talk."  At  times  she  could  hardly 
be  understood;  her  speech,  she  thought,  had  changed. 
There  had  also  been  difficulty  in  swallowing,  but  there  had 
not  been  actual  regurgitation,  either  of  food  or  water.  Of  late, 
she  had  had  difficulty  in  moving  her  tongue;  this  was  more 
marked  as  the  day  wore  on  and  she  grew  increasingly  tired. 
She  had  had  transient  diplopia  and  at  times  much  weakness 
of  the  hands.  While  feeding  the  mangle,  for  example  (she 
was  a  laundress),  she  found  that  her  hands  would  finally  give 
out  completely,  but  that  she  could  go  on  again  about  as  well 
as  before  after  a  short  rest.  Again,  she  was  unable  to  dress 
or  undress  herself  properly  on  account  of  tire  and  accom- 
panying weakness.  In  highly  coordinated  muscular  acts, 
like  buttoning,  the  fingers  would  finally  refuse  entirely  to  work. 
Frequently,  when  talking,  she  would  somewhat  suddenly  begin 
to  stutter  and  her  speech  would  then  become  so  confused 
and  thick  that  it  often  became  unintelligible,  recovering  again 
after  a  rest.  On  one  occasion  she  felt  as  if  choking  and  had 
difficulty  in  breathing.  This  lasted  for  about  a  day  and  then 
improved.  Walking  also  tired  her  easily.  She  was,  in  general, 
much  more  easily  fatigued  than  formerly  by  any  continued 
muscular  movement. 

Physical  examination  showed  the  following  conditions 
bearing  out  entirely  the  patient's  statements  regarding  mus- 
cular weakness.  The  pupils  gave  a  good  light  and  accommo- 
dative response,  and  there  was  no  palsy  of  any  of  the  ocular 
movements;  the  visual  fields  were  normal.  The  lids,  however, 
both  shut  and  opened  very  imperfectly;  it  was  apparently 
somewhat  harder  for  her  to  close  her  eyes  than  to  open  them, 
and  impossible  to  keep  the  lids  closed  against  resistance; 
winking  was  weakly  performed.  The  sensation  of  the  face 
was  unaffected,  and  at  the  time  of  examination  there  was  no 
apparent  weakness  of  the  muscles  of  mastication.  Chewing 
movements  had,  however,  at  times  been  difficult.    Hearing  was 


266  CASE   HISTORIES    IN    NEUROLOGY. 

intact.  The  face  was  Imperfectly  movable  on  both  sides 
and,  in  consequence,  was  somewhat  expressionless;  fine 
muscular  movements  of  the  face  were  impossible.  The  tongue 
was  protruded  somewhat  imperfectly,  but  its  movements 
were  possible  and  it  was  not  atrophied.  The  pharyngeal 
reflex  was  present.  In  other  respects  the  cranial  nerves 
showed  no  invoh^ement.  Hand  grasp  was  good  on  both 
sides  and  not  easily  exhausted.  Wrist  and  elbow  jerks 
were  not  obtained.  Sensation  of  the  arms  was  normal. 
The  knee  jerks  were  active  and  were  not  exhausted  after  a 
hundred  or  more  blows.  Further  testing  of  muscular  fatigue 
showed  that  the  constrictors  of  the  pupil  tired  after  four  or 
five  flashes  of  a  bright  electric  light.  An  attempt  to  repeat 
the  alphabet  rapidly  a  number  of  times  finally  led  to  confusion 
and  practical  unintelligibility,  evidently  through  muscle 
tire.  The  electrical  reactions  varied  in  different  groups  of 
muscles.  An  interosseous  muscle  was  easily  exhausted,  a 
forearm  flexor  uncertainly  and  a  facial  muscle  not  at  all  by 
electrical  stimulation.  An  electrical  examination  on  another 
occasion  showed  a  decidedly  greater  tendency  to  exhaustion. 

Diagnosis.  This  is  undoubtedly  a  case  of  Myasthenia 
Gravis.  The  tendency  to  muscular  fatigue  on  exertion,  often 
amounting  to  temporary  paralysis,  with  quick  recovery  on 
cessation  of  work,  is  characteristic  of  this  disease  of  unknown 
etiology.  A  quick  tiring  of  muscles  on  continued  electrical 
stimulation,  known  as  the  "  myasthenic  reaction,"  is  pathogno- 
monic. The  inconstancy  of  the  paralysis  is  sufficient  to  dif- 
ferentiate it  from  conditions  of  nuclear  ophthalmoplegia 
(see  Case  83)  or  bulbar  lesions  of  similar  type,  though  in  cer- 
tain stages  it  may  easily  be  mistaken  for  such  lesions. 

Prognosis.  The  outlook  for  recovery  is  poor  and  for  life 
uncertain.  There  is  always  danger  of  sudden  death  when  the 
lower  cranial  nerves  are  affected;  on  the  other  hand,  remis- 
sions are  frequent  and  often  of  considerable  duration. 

Treatment.  No  efficient  treatment  for  the  condition  is 
known.  Much  may,  however,  be  done  by  way  of  prophylaxis 
in  warning  against  over-exertion  and  particularly  in  urging 
extreme  care  when  the  nerves  of  deglutition  and  respiration 
are  involved. 


CONDITIONS    OF   VAGUE    PATHOLOGY.  267 

Case  104.  R,  a  married  woman  of  fifty-seven,  had  suffered 
for  five  years  from  a  burning  sensation  in  both  hands.  She 
also  had  a  similar  sensation  in  the  face.  Cold  seemed  to  be 
the  cause.  The  condition  was  always  worse  in  cold  weather, 
although  it  continued  to  a  certain  extent  during  the  summer. 
She  had  particularly  noticed  that  putting  her  hands  in  cold 
water  produced  this  burning  sensation.  For  two  or  three  years 
she  had  noticed  numbness  of  the  hands,  unequal  on  the  two 
sides,  especially  at  night.  The  lifting  of  a  watch,  for  example, 
was  at  one  time  hardly  perceived.  She  also,  at  times,  had 
considerable  pain,  associated  with  the  numbness,  but  without 
muscular  weakness.  Her  feet  were  never  so  affected.  In 
other  respects,  she  regarded  herself  as  well.  She  had  on 
occasions  been  conscious  of  heart  palpitation  but  had  not 
suffered  from  shortness  of  breath.  She  had  had  no  definite 
headache  but  had  had  chronic  constipation  for  years. 

Examination  gave  normal  light  reactions  and  normal  visual 
fields.  There  was  no  objective  disorder  of  sensation  in  the 
face,  palsy  or  other  disturbance  of  any  of  the  cranial  nerves. 
The  heart  was  normal ;  the  pulse  regular,  soft,  88 ;  the  knee 
jerks  were  normal.  Careful  examination  of  the  hands  with 
reference  to  disordered  sensation  showed  no  abnormality 
either  to  heat,  cold,  pain,  contact  or  in  the  stereognostic 
sense.  The  wrist  jerks  were  normal  and  the  strength 
unimpaired. 

Diagnosis.  Acroparesthesia,  an  affection  without  objec- 
tively discoverable  basis,  characterized  by  numbness  and 
parathesia  of  the  extremities,  chiefly  the  hands,  often  seen 
in  persons  who  are  obliged  to  use  the  hand  under  conditions 
of  rapid  change  of  temperature,  as  in  washing,  is  explanatory 
of  the  foregoing  condition. 

Prognosis.  The  outcome  is  usually  favorable  if  the  excit- 
ing cause  can  be  removed.  It  not  infrequently  happens, 
however,  that  such  disordered  sensations  persist  for  many 
years,  suggesting  a  low-grade  neuritis. 

Treatment.  The  patient  should  abstain  from  the  kind 
of  work  or  the  conditions  under  which  the  affection  develops. 
If  no  such  exciting  conditions  are  discoverable,  the  difficulty 
must  be  treated  on  the  general  principle  that  the  local  affec- 


268  CASE   HISTORIES    IN   NEUROLOGY. 

tion  is  a  manifestation  of  a  general  disorder.  It  will  often 
be  found  that  hygienic  measures  combined  with  tonic  drugs, 
electricity  and  massage  are  efficacious.  It  is  important  to 
protect  the  hands  as  far  as  possible  from  the  extremes  of  heat 
and  cold  and  of  moisture  and  dryness. 


CONDITIONS   OF   VAGUE    PATHOLOGY.  269 

Case  105.  O.,  a  man  of  thirty-two,  three  years  before  being 
seen  had  had  an  unexplained  gastric  disorder.  While  working, 
he  had  had  a  sudden  attack  of  vertigo  without  confusion. 
He  vomited.  A  little  later,  he  had  a  very  similar  attack, 
first  a  feeling  of  discomfort  followed  by  dizziness  and  a  period 
of  vomiting  lasting  for  two  hours,  much  of  it  bile.  There  was 
also  very  great  nausea  and  general  discomfort.  He  had  con- 
tinued to  have  such  attacks  at  irregular  intervals  for  three 
months.  He  had  then  improved  somewhat.  He  was  treated 
by  a  physician  for  two  years,  primarily  for  the  stomach 
condition,  with  absolutely  no  relief.  On  one  occasion  while 
using  a  desk  telephone  with  his  eyes  fixed  on  a  bright  light 
he  suddenly  had  a  violent  attack  of  vomiting.  Thinking 
from  this  that  his  eyes  might  be  the  source  of  his  difficulty, 
he  consulted  an  ophthalmologist,  who  corrected  a  refractive 
error.  He  was  somewhat  improved  by  wearing  glasses. 
Later,  while  reading  in  a  train,  the  car  in  which  he  was  sitting 
suddenly  seemed  to  bend  over.  He  closed  his  eyes  and  when 
he  again  opened  them,  everything  appeared  normal.  His 
stomach  was  secondarily  affected.  This  attack  evidently 
differed  from  those  he  had  had  before.  He  was  from  this  time 
disturbed  by  quickly  passing  objects,  such  as  trains  or  auto- 
mobiles. Thereafter  he  had  repeated  more  or  less  abortive 
attacks,  some  resembling  the  original  ones  and  others  consist- 
ing merely  of  peculiar  sensations,  occasioned,  for  example, 
by  looking  down  or  intently  at  objects;  but  these,  in  general, 
were  relatively  slight  and  could,  he  thought,  be  overcome 
by  certain  devices  which  he  practiced.  Further  correction 
of  the  eyes  seemed  to  help  somewhat.  At  length  he  had  a 
violent  attack  beginning  with  a  feeling  of  discomfort  in  his 
head,  followed  by  excessive  vomiting,  with  persistent  vertigo. 
This  he  regarded  as  one  of  the  worst  he  had  had. 

When  seen,  following  this  attack,  the  examination  showed 
that  he  was  distinctly  deaf  in  the  left  ear  and  had  had  tinnitus 
on  that  side  for  two  or  three  years.  He  gave  no  history  of 
general  headache  or  of  vomiting,  apart  from  the  vertigo. 
He  was  somewhat  nervous  in  manner  and  naturally  discour- 
aged. He  had  never  lost  consciousness  in  any  attack  and  had 
never  actually  fallen,  although  he  might  have  done  so  had  he 


270  CASE   HISTORIES    IN    NEUROLOGY. 

not  lain  down.  He  did  not  smoke,  and  drank  to  a  very  slight 
extent.  The  knee  jerks  were  active.  In  general,  apart 
from  the  deafness,  there  was  no  discoverable  disorder  of  the 
nervous   system. 

He  was  ,  referred  to  an  aurist,  who  regarded  the  vertigo 
presumably  as  aural  in  origin.  The  treatment  at  first  was 
middle  ear  inflation,  which  resulted  in  no  material  benefit. 
When  seen  three  months  and  a  half  later,  attacks  of  dizziness 
with  vomiting  persisted,  although  not  so  severe  as  previously. 
His  appetite  and  sleep  were  satisfactory.  The  pupils  gave 
a  good  light  reaction.  The  fundus  was  clear,  the  outlines  of 
the  disks  distinct,  with  no  trace  of  swelling;  the  heart  was 
normal;  pulse  regular,  64.  He  had  had  no  scotomata  asso- 
ciated with  his  attacks  of  vertigo.  Fixation  of  the  stapes  was 
demonstrated  and  the  left-sided  deafness  became  practically 
complete.  The  stapes  was  finally  removed  with  complete 
cessation  of  symptoms  up  to  the  present  time. 

Diagnosis.  This  patient  undoubtedly  suffered  from  Audi- 
tory Vertigo  or  Meniere's  disease,  due  to  disturbance  in  the 
internal  ear  through  fixation  of  the  stapes.  In  this  case, 
the  patient  was  treated  for  two  years  for  a  supposed  primary 
stomach  disorder.  Had  an  aural  examination  been  made, 
this  unfortunate  mistake  presumably  would  not  have  oc- 
curred. The  differential  diagnosis  from  gastric  disease  is 
sometimes  difficult  but  should,  as  a  rule,  be  determined  by  the 
periodic  character  of  the  attacks,  by  the  absence  in  the  free 
intervals  of  demonstrable  stomach  disorder  and  by  the  pres- 
ence of  deafness,  usually  with  tinnitus  associated  with  vertigo. 
The  differentiation  from  epilepsy  is  determined  by  the  ab- 
sence of  convulsive  movements  in  auditory  vertigo  and  also, 
as  just  stated,  by  the  actual  presence  of  disorder  of  hearing. 
The  vertigo  of  brain  tumor  is  rarely  so  paroxysmal  in  char- 
acter and  is  usually  associated  with  changes  in  the  optic 
disk  and  other  signs  of  intracranial  pressure.  In  all  conditions 
of  paroxsymal  vertigo,  particularly  if  accompanied  by  vomit- 
ing, a  painstaking  aural  examination  should  be  made. 

Prognosis.  The  patient  will  undoubtedly  remain  free  from 
vertigo,  provided  the  other  ear  does  not  become  affected. 
In  general,  the  outlook  for  relief  of  the  vertigo  is  good  when 


CONDITIONS    OF   VAGUE    PATHOLOGY.  27 1 

complete  deafness  supervenes  or  when  deafness  is  induced 
artificially  by  the  removal  of  the  stapes.  Less  radical  treat- 
ment, such  as  middle  ear  inflation,  is  usually  not  of  perma- 
nent service. 

Treatment.  As  already  indicated,  the  treatment  may  be 
either  palliative,  when  it  is  usually  inefficacious,  or  radical, 
through  operation,  by  removal  of  the  stapes,  which  often 
results  in  complete  cure.  A  contra-indication  for  surgical 
intervention  is  involvement  of  both  ears,  unless  complete 
deafness  be  considered  preferable  to  the  vertigo.  Lumbar 
puncture  has  been  done  as  a  means  of  relief. 


272  CASE    HISTORIES    IN    NEUROLOGY. 

Case  io6.    L.,  a  married  man  of  thirty-three,  a  blacksmith 

by  occupation,  a  year  before  had  begun  to  suffer  from  pain 
in  the  sole  of  the  left  foot;  this  had  lasted  for  about  three 
months  and  then  ceased;  nine  weeks  before  being  seen  the 
toes  and  the  foot  became  perfectly  white  and  cold.  This 
appearance  changed  from  time  to  time  to  a  distinct  flushing 
of  greater  degree  than  normal,  with  a  persistence  of  the  sen- 
sation of  cold,  though  not  so  extreme  as  when  the  foot  was 
pale.  In  general  the  foot  was  apt  to  be  flushed  indoors, 
and  pale  out  of  doors.  The  pain  occurred  for  the  most  part 
at  night,  starting  about  nine  o'clock,  and  often  assumed  a 
high  degree  of  severity.  The  other  foot  and  the  hands  had  not 
been  affected.  He  had  never  frozen  his  feet  but  had  noticed 
a  tendency  to  sweating;  he  had  worked  in  a  dry  place. 
Ten  days  before  his  visit,  he  had  noticed  a  blister  on  the  under 
side  of  the  right  great  toe.  Pus  formed ;  the  ulcer  was  opened 
but  had  not  healed  since. 

Examination  showed  pupils  normal  to  light  and  accommoda- 
tion; normal  wrist  and  knee  jerks;  a  normal  and  regular 
pulse  of  80.  The  right  foot  was  flushed;  the  dorsalis  pedis 
artery  was  not  palpable;  sensibility  was  unimpaired;  all 
movements  were  possible.  There  was  a  large  open  ulcer 
on  the  under  side  of  the  right  great  toe  surrounded  by  much 
dead  skin.  Between  the  small  and  next  toe,  there  was  also 
an  ulcerated  surface  of  similar  character.  He  had  twinges  of 
pain  during  the  examination. 

Diagnosis.  This  case  is  to  be  classified  as  a  trophic  (vaso- 
motor) disturbance  analogous  to,  if  not  identical  with,  Ray- 
naud's disease.  Its  unusual  feature  is  its  limitation  to  one 
foot.  Raynaud's  disease,  or  so-called  Symmetrical  Gangrene, 
ordinarily  begins  in  the  hands  and  Is  bilateral  in  distribution. 
It  occasionally  happens,  however,  that  a  similar  process 
occurs  in  a  single  extremity,  as  in  this  case.  The  trophic 
disorders  of  tabes  do  not  involve  the  vasomotor  system  in  this 
way.  The  formation  of  painless  ulcers  in  that  disease  is 
common,  with  small  tendency  toward  healing,  but  in  such  cases 
the  general  sensibility  of  the  foot  is  involved,  and  other  signs 
pointing  to  tabes  are  present,  as,  for  example,  pupillary 
changes,    lost  deep   reflexes,   and   general   sensory  disorders. 


CONDITIONS    OF    VAGUE    PATHOLOGY.  273 

Prognosis  and  Treatment.  The  condition  often  improves 
spontaneously,  but  with  a  constant  tendency  to  recurrence 
and  a  reopening  of  apparently  healed  ulcers.  Drugs  are 
unavailing.  A  tourniquet  applied  to  the  leg  and  quickly 
released  occasionally  brings  relief,  after  the  method  advocated 
by  Bier. 


274  CASE    HISTORIES    IN    NEUROLOGY. 

Case  107.  O.,  a  woman  of  thirty-four,  a  teacher  by  occu- 
pation, always  worked  at  higli  tension;  she  had  had  in  the 
past  Aarious  nervous  disturbances  with  temporary  incapa- 
city for  work,  and  in  general  regarded  herself  as  a  person  of 
ner\'Ous  temperament.  For  a  year  she  had  had  slight  twinges 
of  pain  in  the  distribution  of  the  right  fifth  nerve;  at  first 
the  upper  (supra-orbital)  branch  was  more  affected;  later 
the  pain  extended  to  the  lower  branches;  she  continued  at 
her  work.  The  pain,  however,  was  so  persistent  that  she 
consulted  a  rhinologist,  who  said  that  there  was  no  source  of 
irritation  in  the  nose.  The  eyes  had  also  been  examined,  with 
negative  result.  Her  hearing  was  unimpaired;  her  teeth 
had  been  drawn  on  the  upper  jaw  on  the  affected  side.  The 
week  before  being  seen  she  had  worked  particularly  hard, 
and  had  also  been  exposed  to  draughts.  The  occurrence  of 
menstruation  also  seemed  to  render  the  pain  worse;  the  dis- 
comfort was  not  constant,  but  the  pain  occurred  in  violent, 
short  attacks  localized  about  the  nose  and  lower  jaw.  She 
had  difficulty  in  speaking  and  eating  on  account  of  the  excita- 
tion of  pain.  She  had  taken  castor  oil  without  definite  effect, 
as  well  as  bromide  of  strontium,  and  hyoscyamus.  It  was 
finally  necessary  to  resort  to  small  doses  of  morphine.  Rest 
and  cessation  of  work  was  ordered,  and  this  seemed  to  bring 
some  relief;  at  one  time  she  had  had  a  respite  of  two  weeks. 
On  her  own  initiative  she  had  finally  had  all  but  three  teeth 
drawn  in  the  lower  right  jaw. 

During  this  period  of  enforced  rest,  she  wrote  as  follows: 
"  The  third  and  most  awful  seizure  of  tic  has  been  using  up 
my  vitality  for  the  last  nine  days.  A  quarter  of  a  grain  of 
morphine  with  atropine  had  no  effect.  It  was  necessary 
to  have  two  such  hypodermics  during  a  night,  together  with 
trional  and  other  strong  quieting  things.  Resting  under  such 
conditions  is  not  simple."  And  again  a  little  later:  "  The  limit 
of  my  endurance  of  suffering  is  approaching;  the  serious  at- 
tack of  tic  that  I  had  the  first  of  July  lasted  until  the  19th 
of  August.  The  following  two  weeks  I  was  about,  driving, 
tramping,  and  able  to  talk  naturally.  The  relief  at  that  time 
we  supposed  was  due  to  the  discovery  and  removal  of  a  stony 
growth,  —  a  pulp  nodule  in  the  nerve  cavity  of  the  cuspid 


CONDITIONS   OF   VAGUE    PATHOLOGY.  275 

tooth;  the  tooth  was  devitalized  and  the  growth  removed. 
Then  I  took  a  slight  head  cold,  the  inflammation  from  which 
pressed  on  the  trigeminal  and  caused  tic.  Upon  further  con- 
sultation with  the  dentist  and  the  doctor,  it  seemed  advisable 
to  have  the  wisdom  tooth  extracted  from  that  same  right 
side.  We  found  that  the  tooth  had  a  large  extra  prong  or 
root,  which  may  have  irritated  the  nerve.  However,  the 
extraction  of  it  so  disturbed  or  bruised  the  nerve  that  I 
have  had  all  those  terrific  paroxysms  ever  since;  that  is, 
for  the  last  twelve  days.  I  had  morphine  for  four  days,  but 
nothing  since." 

The  pain  persisted  at  intervals,  in  spite  of  medication  and 
such  measures  as  detailed  above.  A  careful  and  pains- 
taking regulation  of  her  digestive  functions  apparently 
helped  the  situation  for  a  time  and  reduced  the  attacks  of 
pain.  She  gained  somewhat  in  weight,  and  in  general  her 
physical  condition  was  temporarily  greatly  improved.  The 
pain,  however,  recurred  in  distressing  form,  and  alcohol 
injections  into  the  nerve  at  the  hands  of  a  skilled  operator 
resulted  in  a  decided  amelioration  of  the  pain.  It  was  deemed 
unadvisable  to  undertake  the  more  radical  operation  of 
removal  of  the  Gasserian  ganglion,  or  deep  section  of  the 
offending  nerves.  In  general,  the  patient  was  greatly  bene- 
fited by  the  less  radical  procedure,  and,  so  far  as  known, 
has  lived  in  moderate  comfort  since. 

Diagnosis.  This  is  an  instance  of  Trigeminal  Neuralgia 
(tic  douloureux)  occurring  in  a  somewhat  young  person  of 
decidedly  nervous  temperament.  The  sharp  localization 
of  the  pain,  its  paroxysmal  character  and  its  extreme  inten- 
sity absolutely  exclude  it  from  the  category  of  a  simple 
neurotic  disturbance.  The  etiology  Is  obscure;  there  was  no 
evidence  of  a  sufificlent  local  source  of  irritation  In  the  nasal 
cavity,  In  the  sinuses  or  in  the  teeth  to  account  for  the  pain; 
therefore,  as  In  many  of  these  cases,  the  cause  of  the  neuralgia 
must  be  sought  In  the  general  condition  of  the  patient  rather 
than  In  a  definite  local  source  of  irritation.  The  extraction 
of  the  teeth  clearly  did  not  remedy  the  condition,  and  it  Is 
altogether  doubtful  whether  this  frequent  source  of  facial 
neuralgia  was  In  any  way  operative  in  this  case. 


276  CASE   HISTORIES    IN    NEUROLOGY. 

Prognosis.  The  patient  improved  greatly  after  benumbing 
the  ner\-e  through  injections  of  alcohol.  It  is  probable  that 
the  pain  will  recur  at  inter\'als  during  life,  \'ery  possibly  de- 
manding radical  surgical  procedure  for  its  ultimate  relief. 

Treatment.  In  this  case  the  usual  preliminary  measures 
of  treatment  were  undertaken  without  definite  result.  The 
bromides,  and,  later,  morphine,  were  administered,  together 
with  large  doses  of  castor  oil,  which  is  often  an  efficient 
remedy.  Careful  examination  was  made  of  the  teeth,  of  the 
eyes  and  of  the  nasal  cavity  as  possible  sources  of  irritation ; 
the  digestive  tract  was  most  carefully  regulated,  resulting 
in  a  gain  of  weight;  but  all  these  measures  failed  to  relieve 
the  facial  pain.  The  mechanical  method  of  injecting  alcohol 
into  the  ner\'e  proved  temporarily  efficacious,  as  it  must 
invariably  do,  if  the  nerve  is  reached  by  the  injection.  No 
further  operation  was  attempted,  in  consideration  of  the 
youth  of  the  patient,  and  of  the  fact  that  the  pain  in  any 
event  was  not  constant. 


CONDITIONS   OF   VAGUE    PATHOLOGY.  277 

Case  108.  G,,  a  man  of  thirty-five,  had  worked  hard  for 
five  years  under  trying  conditions,  with  few  vacations. 
A  month  before  being  seen,  he  was  depressed,  stopped  smok- 
ing and  drank  black  coffee,  but  without  special  effect  on  his 
spirits.  About  a  week  later  he  noticed  pain  about  the  left 
side  of  the  body  at  the  level  of  the  umbilicus.  This  was  fol- 
lowed in  three  or  four  days  by  an  eruption  In  the  same  area 
In  which  he  had  had  pain.  He  became  increasingly  nervous 
and  stayed  away  from  his  work  for  a  number  of  days.  He 
was  waked  at  night  by  the  neuralgic  pain.  So  far  as  he  knew, 
he  had  had  no  fever  at  any  time.  When  examined,  between 
two  and  three  weeks  after  the  onset  of  the  neuralgia  and  erup- 
tion, he  appeared  exhausted  and  In  poor  condition.  He 
thought  his  attention  was  defective,  his  sleep  had  been  much 
interrupted,  the  neuralgic  pain  in  his  back  had  gone,  but 
he  still  had  superficial  discomfort  with  a  sense  of  stinging. 
His  bowels,  previously  constipated,  were  now  normal.  He 
was  drinking  very  little  alcohol. 

The  physical  examination  showed  pupils  normal  to  light 
and  on  accommodation;  normal  heart,  with  a  regular  but 
somewhat  rapid  pulse.  The  knee  jerks  were  also  normal. 
A  definite  herpetic  eruption,  partially  healed,  extended  about 
the  body  on  the  left  side  at  the  level  of  the  umbilicus. 

When  seen  again  at  the  end  of  a  week,  he  had  Improved 
in  every  way.  He  slept  satisfactorily;  the  Intercostal  pain 
was  better  and  the  eruption  was  disappearing.  He  was  able 
to  walk  and  also  to  work,  and  his  appetite  was  good. 

Diagnosis.  The  patient  was  suffering  from  Herpes  Zoster, 
involving  the  distribution  of  one  and  a  part  of  a  second 
intercostal  nerve  on  the  left.  Previous  to  the  appearance  of 
the  eruption,  such  cases  are  often  regarded  as  simple  neuralgia. 
In  intercostal  pain,  therefore,  a  careful  Inspection  of  the 
body  should  be  made  not  only  at  the  time  of  the  first  appear- 
ance of  pain,  but  also  later  In  order  to  determine  the  presence 
of  an  herpetic  eruption.  The  eruption  itself,  limited  to  one 
or  more  nerve  distributions.  Is  not  to  be  mistaken  for  other 
lesions. 

Prognosis.  The  disease  Is  self-limited  and,  as  in  this  case, 
tends  to  spontaneous  recovery. 


278  CASE   HISTORIES    IN   NEUROLOGY. 

Treatment.  The  treatment  is  palliative  rather  than  cura- 
tive. The  preliminary  pain  may  be  treated  by  the  milder 
analgesics,  followed,  if  necessary,  by  codeine  or  morphine. 
When  the  vesicles  appear,  they  should  be  carefully  protected 
from  overlying  clothing  and  dusted  with  a  simple  powder, 
such  as  oxide  of  zinc.  Surgical  cleanliness  should  be  insisted 
upon.  The  later  stages  are  best  treated  by  means  designed 
to  build  up  the  general  resistance  and  to  insure  such  physical 
comfort  as  is  possible.  In  this  case,  galvanism  applied  about 
the  body  and  bromide  of  potassium  in  doses  of  from  10  to 
20  grains  at  night,  together  with  encouragement  and 
explanation,  sufficed  to  accomplish  excellent  results. 


CONDITIONS    OF   VAGUE    PATHOLOGY.  279 

Case  109.  (A.)  I.,  a  man  of  fifty-three,  had  worked  as  a 
stone-cutter  for  many  years;  three  years  before  being  seen,  he 
had  had  some  difficulty  with  his  hand,  which,  however,  quickly 
recovered,  and  he  was  able  to  return  to  his  work.  A  few 
months  later,  after  a  period  of  idleness,  he  began  to  work  again, 
and  then  noticed  pain  in  the  thumb,  wrist  and  back  of  the 
left  hand,  running  up  the  arm;  this  pain  recurred  only  when 
he  was  at  work,  and  finally  became  so  troublesome  that  he 
was  unable  to  hold  the  tool  used  in  stone-cutting  in  the  left 
hand;  for  this  reason  he  was  obliged  to  give  up  work.  He 
had  a  feeling  of  numbness  In  the  thumb,  but  physical  exami- 
nation of  the  arm  and  hand  showed  no  objective  abnormality. 
The  pupils,  knee  jerks,  reflexes,  motility  and  sensibility 
were  all  normal. 

(B.)  A  woman  of  forty,  unmarried,  had  for  ten  years 
done  much  work  with  her  arms  in  the  nature  of  gymnastics 
and  massage ;  at  the  end  of  eight  years  she  had  experienced 
a  gradual  onset  of  weakness  and  sense  of  heaviness,  together 
with  trembling  of  both  arms;  the  sensation  was  as  if  "  they 
were  going  to  sleep."  She  gave  up  her  work  for  six  months, 
and  appeared  to  be  relieved  temporarily  by  vibratory  treat- 
ment; she  then  returned  to  work,  and  had  been  active  since. 
She  thought  she  had  not  grown  worse,  but  constantly  noticed 
the  unpleasant  sensations  referred  to,  after  finishing  a  treat- 
ment of  massage.  She  was  somewhat  tired  and  of  nervous 
temperament,  but  in  general  well;  her  sleep  was  reasonably 
satisfactory,  but  she  often  took  trional.  She  suffered  from 
constipation.  Apart  from  the  disturbance  in  her  arms 
and  a  coincident  difficulty  in  writing,  on  account  of  tremor 
and  pain,  she  considered  herself  well.  The  physical  examina- 
tion showed  a  considerable  degree  of  tenderness  over  the  ner^-e 
trunks  of  the  whole  right  arm ;  both  active  and  passive  move- 
ments were  free,  and  there  was  no  disorder  of  objective  sen- 
sibility or  of  motility;  the  knee  jerks  were  active,  the  pupils 
normal,  the  pulse  120;  she  was  excitable  in  manner.  At 
a  later  visit  she  showed  general  improvement  in  her  nervous 
condition,  but  her  arms  were  no  better;  she  was  continuing 
to  give  massage. 

(C)    A  married  woman   of   thirty- two,  after  a  period  of 


28o  CASE   HISTORIES    IN    NEUROLOGY. 

excessive  piano  playing,  noticed  a  tingling  sensation,  with  some 
sense  of  throbbing  in  the  right  upper  arm;  the  left  arm  was 
also  affected  in  a  similar  way,  but  less  severely.  She  had 
played  the  piano  persistently  for  many  years,  and  on  a  pre- 
vious occasion  had  had  a  similar  trouble  to  that  for  which 
she  was  seeking  advice.  She  was  in  general  well,  but  had  little 
endurance;  housekeeping  and  the  care  of  her  children  were 
irksome,  but  she  had  no  real  anxieties;  her  appetite  and  sleep 
were  satisfactory.  She  had  worried  considerably  lest  the 
difficulty  in  her  arms  should  prove  to  be  serious.  She  also 
had  similar  sensations  when  she  wrote,  and  she  was  in  general 
worse  when  tired  or  when  she  used  her  arms.  Examination 
showed  no  objective  disorder,  either  of  sensation  or  motion; 
the  faradic  irritability  of  the  muscles  was  retained. 

{D.)  A  man  of  forty-seven  had  during  the  greater  part 
of  his  liTe  worked  as  a  bookkeeper;  up  to  a  year  and  a  half 
before  being  seen  he  had  written  steadily  and  without  dis- 
comfort ;  he  then  noticed  that  writing  was  done  with  increas- 
ing effort  and  that  he  was  obliged  to  grasp  his  pen  tightly 
in  order  to  write  smoothly;  this  had  grown  worse;  he  had 
much  feeling  of  discomfort,  particularly  in  the  flexor  muscles 
of  the  forearm.  He  was  well  in  other  respects,  and  was  able 
to  do  other  things  with  the  hands  without  discomfort.  His 
writing  had  been  reduced  to  not  more  than  half  an  hour  a  day, 
excepting  for  one  day  at  the  end  of  each  month.  He  had  tried 
various  forms  of  treatment  without  avail.  The  pupils  and 
knee  jerks  were  normal,  and  there  was  no  objective  dis- 
turbance, either  of  sensation  or  motion  in  the  hand.  He 
complained  particularly  of  pain  running  up  the  right  arm, 
for  which  there  was  no  discoverable  objective  cause. 

Diagnosis.  These  four  cases  illustrate  types  of  Occupation 
Neuroses.  The  diagnosis  is  made  from  the  onset  of  localized 
pain  and  incapacity  in  certain  groups  of  muscles  used  con- 
stantly for  the  same  or  similar  purposes.  It  is  of  interest, 
that  in  Cases  B  and  C  writing  was  difficult,  as  well  as  the 
special  work  which  induced  the  disturbance,  showing  that  in 
some  cases  at  least  the  sharp  limitation  of  the  disorder  to 
groups  of  muscles  concerned  in  a  specialized  form  of  work 
is  rather  apparent  than  real.    The  etiology  of  these  conditions 


CONDITIONS    OF   VAGUE    PATHOLOGY.  28 1 

is  not  definitely  determined.  Over-use  of  muscle  groups 
appears  in  all  cases  to  be  a  predisposing  factor;  whether  a 
low  grade  of  neuritis  results  therefrom,  through  pressure  or 
other  cause;  whether  the  condition  is  rather  to  be  explained 
by  a  disorder  of  the  cerebral  mechanism ;  or  whether,  as  seems 
most  probable,  both  the  peripheral  and  the  central  disturb- 
ance must  be  considered  in  combination,  are  matters  as  yet 
not  clear. 

Prognosis.  The  outcome  of  the  various  forms  of  occu- 
pation neurosis,  as  exemplified  in  the  foregoing  cases,  is 
satisfactory,  provided  the  special  form  of  muscular  work 
which  induced  the  disturbance  be  discontinued. 

Treatment.  Treatment  consists  in  the  removal  of  the  cause. 
The  patients  should  be,  and  were  in  the  cases  quoted,  advised 
if  possible  to  give  up  their  specialized  work  and  to  find  other 
employment.  Psychotherapy  and  drugs  are  of  relatively 
little  avail.  Cessation  from  work  and  rest  of  the  affected 
muscles  is  absolutely  demanded. 


SECTION  V. 

PSYCHONEUROSES. 

In  classifying  the  following  cases  as  "  Psychoneuroses," 
that  term  is  used  In  a  comprehensive  sense  as  Including  those 
conditions  the  explanation  of  which  is  dependent  upon  a 
primary  appeal  to  psychic  factors.  It  has  become  increas- 
ingly apparent  that  the  search  for  a  physical  pathology  In 
affections  of  this  type  has  been  far  less  productive  of  clear 
understanding  than  an  appeal  to  mental  causes.  The  result 
of  this  latter  tendency  in  investigation  has  been  a  more  pains- 
taking analysis  of  mental  states,  with  an  accompanying 
recognition  of  their  etiological  significance,  and  a  consequent 
wider  separation  of  neuropsychoses  from  the  structural  or 
presumably  structural  diseases  of  which  examples  have  been 
given  in  the  preceding  pages.  There  can  be  little  doubt  that 
a  candid  acknowledgment  of  the  psychogenesis  of  the  so- 
called  functional  diseases  will  go  far  toward  clarifying  our 
understanding  of  these  hitherto  obscure  and  elusive  affections. 

Case  no.  C,  a  married  woman  of  forty-one,  without 
children,  gave  the  following  history:  As  a  child  she  was  not 
strong;  as  early  as  the  age  of  twelve  she  became  possessed 
with  the  Idea  that  she  had  a  cancer  under  her  tongue,  and 
suffered  extremely  from  the  Idea;  she,  however,  told  no  one 
of  her  difficulty.  As  a  girl,  she  was  morbid,  and  worried  con- 
stantly about  the  future,  but  in  spite  of  this  managed  to  en- 
joy life.  Her  anxiety  tended  always  to  be  directed  to  herself 
and  her  own  condition ;  she  was  married  at  the  age  of  about 
twenty-eight,  and  thereafter  underwent  what  she  called  an 
attack  of  "  nervous  prostration."  She  felt  unnatural,  and  the 
ordinary  duties  of  her  daily  life  seemed  almost  Impossible; 
she  felt  at  times  as  if  she  were  destined  to  be  deformed, 
because  she  had  pain  In  certain  joints.  She  lived  thereafter 
in  constant  fear  of  incurable  disease,  and  was  much  depressed 

283 


284  CASE   HISTORIES    IN    NEUROLOGY. 

thereby.  All  her  anxieties,  however,  appeared  to  have  some 
basis,  though  invariably  inadequate,  in  her  physical  condition. 

The  difficulty  for  which  she  particularly  sought  advice 
had  resulted  from  an  inter\'iew  with  her  physician  about  a  year 
previously;  she  was  at  that  time  apparently  suffering  from 
a  slight  cold,  or  bronchial  irritation,  and  after  examination 
her  physician  remarked  that  she  "  had  some  roughness  of 
respiration,"  and  advised  her  to  spend  her  summer  at  an 
inland  place  rather  than  near  water.  She  asked  no  questions 
at  the  time,  but  forthwith  became  possessed  with  the  idea 
that  her  physician  thought  her  ill  with  tuberculosis.  She 
suffered  extremely  from  this  idea  and  finally  consulted  a  man 
of  high  reputation  in  regard  to  tuberculosis,  who  examined 
her  with  the  greatest  possible  care  on  more  than  one  occasion, 
and  reached  the  conclusion  that  her  lungs  and  throat  were 
entirely  free  from  the  disease.  She  had  no  expectoration  or 
distinct  cough,  but  complained  of  "  awful  feelings  "  about  the 
neck  and  throat,  and,  in  spite  of  reassurance,  was  completely 
overmastered  by  her  fear.  She  slept  badly  and  her  mind 
was  constantly  absorbed  by  her  anxiety.  For  a  year  past  she 
said  that  she  had  not  breathed  or  coughed  without  noticing 
the  effect  on  her  chest. 

When  examined  she  was  exceedingly  depressed  in  manner, 
emotional,  and  continually  asserted  that  she  had,  or  would 
have,  tuberculosis.  This  idea  she  justified  by  the  character 
of  her  sensations,  particularly  referred  to  the  throat  and  chest 
on  the  right  side.  Her  throat,  she  said,  was  dry,  and  she  con- 
tinually justified  the  idea  of  throat  irritation  by  a  manifestly 
artificial  cough,  which  resulted  in  no  expectoration.  In  gen- 
eral she  was  physically  well,  and  showed  no  sign  whatever 
of  any  cachexia.  Apart  from  her  extremely  introspective 
attitude  and  tendency  to  apprehensiveness,  she  was  perfectly 
normal  both  physically  and  mentally. 

She  was  seen  a  number  of  times  thereafter,  for  a  period 
of  a  month,  wdth  slight  variation  In  her  symptoms;  it  was, 
however,  absolutely  impossible  to  dislodge  her  fixed  idea  for 
any  length  of  time,  In  spite  of  long-continued  explanation 
and  argument.  Another  visit  to  the  specialist  in  tuberculosis, 
in  whom  she  professed  much  confidence,  resulted  in  nothing 


PSYCHONEUROSES.  285 

more  than  a  temporary  amelioration  of  her  morbid  fear. 
A  characteristic  remark  made  at  this  time  was  that  "  she 
would  not  mind  the  sensations  through  her  chest,  were  she 
sure  the  condition  was  not  going  to  grow  worse." 

Diagnosis.  It  is  difificult  to  label  a  neurosis  of  this  type, 
but  it  illustrates  well  the  condition  known  as  Hypochon- 
driasis, characterized  particularly  by  a  fear  of  physical 
disease.  The  etiology  in  this  case  was  not  determined  further 
than  that  from  childhood  the  patient  had  been  a  victim  of 
morbid  fears,  directed  toward  herself,  and  chiefly  of  a  physi- 
cal sort.  The  underlying  cause  of  these  primary  fears  was 
not  ascertained,  though  it  is  altogether  probable,  with  a 
more  complete  analysis,  that  certain  exciting  factors  might 
have  been  elicited.  The  fact  desirable  to  point  out  here  is 
that  such  a  condition  beginning  in  childhood  is  likely  to 
develop  with  advancing  years  and  iacreasing  responsibilities, 
often  assuming  different  forms  as  new  conditions  arise. 
The  suggestibility  of  this  patient  was  very  great  in  matters 
regarding  her  own  physical  condition,  as  shown,  for  example, 
by  the  effect  of  an  inadvertent  remark  of  her  physician  regard- 
ing her  breathing,  which  she  forthvv^ith  misinterpreted  to 
her  own  disadvantage. 

Prognosis.  The  patient  disappeared  from  observation 
without  permanent  relief.  The  outcome  depends  upon  a 
reconstruction  of  her  life  and  mental  attitude,  which,  con- 
sidering the  circumstances  under  which  she  lived,  is  likely 
to  prove  exceedingly  difficult.  It  is  probable  that  the  fear 
of  tuberculosis  will  give  place  to  some  other  anxiety  as  time 
goes  on;  but  complete  relief  cannot  be  expected  until  the 
tendency  itself  toward  introspective  anxiety  is  permanently 
allayed;  this  can  only  be  accomplished  by  painstaking  psy- 
chotherapy. 

Treatment.  An  attempt  was  made  in  this  case  to  explain 
the  nature  of  the  difficulty  in  great  detail  in  the  hope  that 
thereby  she  would  be  able  to  overcome  her  morbid  feelings. 
Activity  was  also  insisted  upon  in  the  hope  of  sidetracking 
her  emotional  state;  the  results  were  disappointing.  Tem- 
porary relief  was  apparent,  but  it  was  impossible  so  to  impress 
her  with  the  nature  of  the  difficulty  that  she  was  able  to  carry 


286  CASE   HISTORIES    IN    NEUROLOGY. 

on  her  cure  unaided.  When  last  seen  the  idea  of  tuberculosis, 
although  not  appealing  to  her  reason,  was  still  firmly  fixed 
as  an  emotional  state  in  her  mind. 


PSYCHONEUROSES.  287 

Case  III.  A.,  a  man  of  twenty-seven,  married,  was  em- 
ployed as  a  fireman  in  the  Boston  Fire  Department.  His 
main  complaint,  which  he  admitted  with  some  diffidence, 
was  that  he  was  unable  to  bear  the  rays  of  the  sun,  wholly 
irrespective  of  the  general  temperature.  He  had  been  to  vari- 
ous physicians,  who  had  considered  him  "  nervously  run 
down  "  and  had  prescribed  for  him,  but  to  no  effect. 

The  history,  procured  with  some  difficulty,  was  as  follows: 
He  had  been  married  upwards  of  three  years.  His  wife  had 
had  one  child,  born  at  the  eighth  month;  the  labor  was  diffi- 
cult and  the  child  lived  three  months.  Ten  or  twelve  years 
ago  he  had  had  an  attack  of  what  he  called  malarial  fever. 
Two  years  ago,  in  July,  during  an  exceedingly  hot  period, 
he  had  had  a  similar  attack.  He  was  then  out  of  work  for 
twenty-nine  days  and  when  he  returned,  although  otherwise 
well,  he  had  an  uncontrollable  feeling  that  he  couldn't  stand 
the  heat  of  the  sun.  He  felt,  as  he  expressed  it,  "  as  if  the  sun 
went  through  him  and  as  if  he  were  going  to  fall  to  pieces." 
As  winter  came  on,  he  continued  to  be  affected  by  the  sun 
and  also  began  to  be  troubled  to  a  certain  degree  by  artificial 
heat. 

This  situation  seemed  so  unusual  that  a  further  attempt 
was  made  to  determine  more  in  detail  the  condition  at  or  about 
the  time  of  the  beginning  of  his  neurosis.  It  appeared  that 
he  was  first  taken  sick  when  on  an  excursion.  The  most 
notable  symptom  was  a  sense  of  pressure  In  the  epigastrium. 
This  lasted  all  day.  In  the  evening,  he  smoked  a  cigar  and 
felt  better.  He  went  to  a  large  fire  In  the  course  of  his  duty, 
but  was  unusually  troubled  by  the  smoke  and  was  relieved 
from  duty.  He  was  told  by  his  friends  that  he  looked  badly. 
A  few  days  later  he  had  a  similar  attack  to  the  one  described 
above.  It  was  on  a  very  hot  day;  he  went  home  and  sent  for 
a  physician,  who  at  first  diagnosticated  Indigestion  and  later, 
after  examination  of  the  blood,  malaria.  He  had  another 
similar  attack,  but  gradually  Improved  and  was  working  at 
the  end  of  a  month,  but  felt  exceedingly  weak.  The  following 
summer  he  began  to  Improve  somewhat  but  was  far  from  well. 
He  was  able  to  stand  for  a  time  in  the  sun,  but  during  the  sum- 
mer avoided  doing  so  as  much  as  possible  because  of  the  un- 


288  CASE   HISTORIES    IN    NEUROLOGY. 

pleasant  sensations  of  weakness  and  distress  which  it  occa- 
sioned. He  was  still  able  to  do  his  work  and,  in  fact,  enjoyed 
the  excitement  of  a  fire.  It  had  been  a  source  of  great  dis- 
turbance to  him  that  he  could  not  explain  why  it  was  possible 
to  go  through  various  experiences  of  extreme  heat  and  fire 
and  yet  be  absolutely  incapable  of  standing  the  rays  of  the 
sun.  On  one  occasion,  for  example,  in  winter,  when  it  was  four 
degrees  below  zero,  he  had  the  same  distressing  sensation. 
Added  to  this,  there  developed  a  distinct  fear  of  closed  places 
and  of  crowds.  On  one  occasion  he  felt  himself  absolutely 
unable  to  go  through  a  crowded  street.  He  was  not  alcoholic, 
his  appetite  and  sleep  were  not  impaired.  He  had,  however, 
worried  extremely;  he  felt  as  if  he  "  might  as  well  be  dead  "; 
that  "  life  was  a  burden."  In  trying  to  combat  these  feelings, 
his  courage  failed  aad  he  was  unable  to  accomplish  results. 
He  was  cheerful  in  manner  and  showed  no  signs  of  depression 
beyond  the  general  anxiety  which  his  increasing  incapacity 
occasioned  him.  Actual  nervous  strains  did  not,  however, 
affect  him.  On  one  occasion,  he  narrowly  escaped  with  his 
life  in  an  explosion,  but  w^as  not  at  all  disturbed  thereby. 
On  another  occasion,  when  many  horses  were  burned,  he 
was  obliged  to  stand  on  the  carcasses  of  the  horses  in  attempt- 
ing to  put  out  the  fire,  and  this  also  he  did  without  flinching. 
During  this  period,  however,  he  felt  himself  unable  to  go  to 
the  theater,  although  he  had  the  tickets,  because  of  the  close- 
ness of  the  air.  He  also  found  it  impossible  to  sit  in  a  certain 
chair  which  had  been  used  during  his  illness  with  malaria, 
and  felt  impelled  to  go  to  another  room  and  open  the  windows 
wide,  whatever  the  outside  temperature  might  be.  He  was 
accustomed  to  work  in  a  small,  hot  room  under  conditions 
of  great  discomfort  without  the  slightest  difficulty,  but,  as 
he  expressed  it,  he  was  "  all  gone  "  when  he  went  out  into  the 
sun.  A  consumptive  girl  of  his  acquaintance  sat  much  in  the 
sun.  This  made  him  increasingly  eager  to  avoid  the  sun 
himself  and  he  wondered  how  long  he  could  live  if  she,  in  the 
sun,  would  live  only  a  few  months.  He  wondered  if  he  would 
be  in  this  condition  of  terror  till  he  died.  He  feared  greatly 
another  attack  of  malaria. 

Still  entirely  dissatisfied  with  the  analysis,  further  questions 


PSYCHONEUROSES.  289 

were  asked  regarding  the  attack  of  malaria  two  years  before. 
The  memory  was  not  easy  to  arouse,  but  finally,  after  much 
questioning  (the  method  of  free  association  was  not  used), 
the  simple  fact  came  out  that  during  the  time  of  his  high 
fever  and  discomfort  from  malaria,  the  weather  was  excep- 
tionally hot,  the  temperature  being  well  over  ninety  for  a 
number  of  days.  The  combination  of  his  fever  and  the  ex- 
cessive heat,  together  with  the  fact  that  a  misguided  woman 
was  continually  quoting  the  readings  of  a  thermometer, 
constituted  a  situation  associated  with  great  physical  and 
mental  suffering.  It  was  at  once  clear  that  when  the  fever 
subsided  and  the  temperature  decreased,  the  sense  of  de- 
bility and  actual  fear  of  the  sun  was  invariably  aroused  when 
he  became  conscious  of  the  sun's  rays.  It  was  only  neces- 
sary for  this  one  element  in  the  association  to  be  excited  to 
reproduce  the  entire  distressing  experience  of  his  illness. 

The  matter  was  explained  to  him  at  length,  in  language 
suited  to  his  understanding,  that  he  was  suffering  from  the 
reproduction  of  an  experience  through  which  he  had  actually 
lived  and  from  which  he  had  suffered,  but  that,  one  element 
at  least  —  the  malaria  —  no  longer  existing,  there  was  no 
reason  why  the  distress  occasioned  by  the  combination  of 
sun  and  fever  should  persist.  He  went  away  with  this 
explanation  and  nothing  more  in  the  way  of  treatment. 

Although  the  attempt  was  made  to  learn  of  the  outcome 
of  his  difficulty,  it  was  not  possible  to  have  another  interview 
with  him  for  the  space  of  three  years.  He  then  made  the  fol- 
lowing statement.  He  had  thought  the  explanation  given 
him  reasonable,  but  for  a  time,  although  he  was  helped, 
he  was  still  annoyed  by  the  sun.  He,  however,  met  the  diffi- 
culty in  a  much  more  philosophic  spirit  and  had  been  dis- 
tinctly benefited  by  the  explanation  given  him  of  the  genesis 
of  his  difficulty.  He  had  continued  his  work  as  fireman  and, 
after  about  three  months  of  effort,  following  a  short  vacation, 
he  had  improved  rapidly.  He  said  that  he  was  not ''  bothered 
a  bit  by  the  sun  "  except  on  very  rare  occasions,  when  he  had 
a  certain  slight  recurrence  of  his  old  feelings.  He  was  in  no 
way  incapacitated  and  had  continued  in  the  arduous  work 
of  a  fireman. 


290  CASE    HISTORIES    IN    NEUROLOGY. 

Diagnosis.  The  foregoing  case  is  a  type  of  the  "  Anxiety 
Neurosis,"  based,  so  far  as  the  analysis  went,  on  an  asso- 
ciation between  the  distressing  sensations  caused  by  a  high 
iever  and  the  rays  of  the  sun  during  a  period  of  extreme  heat. 
Recovery  from  the  febrile  condition  took  place,  and  the  ex- 
treme physical  heat  was  also  of  short  duration ;  the  associa- 
tion between  the  two  conditions  was  such,  however,  that 
whenever  he  was  exposed  to  the  rays  of  the  sun,  the  entire 
distressing  series  of  events  was  reproduced  in  consciousness, 
with  the  result  that  he  had  continued  attacks  of,  to  him, 
unexplained  anxiety  whenever  he  found  himself  in  the  sun, 
characterized  by  a  feeling  of  prostration,  extreme  apprehen- 
siveness,  sense  of  weakness  and  incapacity,  combined  with 
a  high  degree  of  dread,  which  rendered  him  practically 
helpless.  Diagnosis  was  made  through  a  relatively  superficial 
analysis  of  the  patient's  life,  and  the  discovery  thereby 
of  an  adequate  cause  for  the  subsequent  distressing  and 
increasing  neurosis. 

Prognosis.  When  this  patient  presented  himself  he  was 
in  an  extremely  discouraged  state,  and  about  to  give  up  his 
work,  which  he  felt  he  was  rapidly  becoming  unable  to  ac- 
complish. Had  the  cause  of  his  peculiar  fear  not  been  found, 
he  would  inevitably  have  been  obliged  to  change  his  occu- 
pation, and  undoubtedly  would  have  become  a  nervous 
Invalid.  The  prognosis,  therefore,  in  this  case,  depended 
wholly  upon  a  proper  analysis  of  the  neurosis  in  relation  to 
its  causative  factor.  This  being  found,  the  outlook  for  the 
future  is  absolutely  good. 

Treatment.  The  treatment  in  this  case  consisted  in  an 
effort,  which  proved  successful,  to  discover  the  cause  of 
the  phobia.  The  explanation  following  this  discovery 
proved  entirely  adequate  to  remove  the  anxiety,  which  had 
so  far  taken  possession  of  the  patient  that  his  work  and  liveli- 
hood were  threatened.  The  fact  that  he  has  been  well  for 
a  period  of  upwards  of  three  years  is  sufficient  demonstration 
of  the  correctness  of  the  therapeutic  measures  undertaken 
In  this  case.  No  drugs  were  given,  and  the  patient  was  seen 
only  once. 


PSYCHONEUROSES.  29 1 

Case  112.  L.,  an  unmarried  woman  of  twenty-one,  a 
kindergarten  teacher,  had  been  troubled  with  uncontrollable 
twitching  of  the  head  some  years  before  being  seen ;  this  had 
developed  suddenly,  and  was  temporarily  a  source  of  great 
annoyance;  she  had  not  been  strong  for  a  number  of  years; 
had  always  had  a  small  appetite,  and  had  had  much  discom- 
fort at  her  menstrual  periods;  she  had  studied  faithfully 
for  two  years  in  preparation  for  her  work,  which,  however, 
was  not  difficult  or  irksome.  Shortly  before  being  seen,  and 
without  apparent  exciting  cause,  twitching  of  the  muscles 
about  the  head  and  face  had  begun  again,  with  renewed  vigor. 
As  she  lay  in  bed  her  head  was  in  almost  constant  motion, 
with  a  tendency  to  turn  toward  the  right,  due  to  a  sharp  and 
almost  constant  spasm  of  the  left  sternomastoid  muscle; 
the  right  sternomastoid  was  also  involved,  but  in  less  degree, 
as  were  also  other  muscles  about  the  neck.  The  jaw  muscles 
were  in  a  state  of  clonic  spasm,  and  the  left  trapezius  was 
said  to  have  been  affected,  especially  at  night.  The  pupils 
and  cranial  nerves  were  normal;  the  pulse  was  ,80,  and 
the  heart  showed  nothing  remarkable;  the  knee  jerks  were 
normal,  and  definite  signs  of  hysteria,  such,  for  example, 
as  hemianesthesia,  or  other  marked  sensory  or  motor  dis- 
orders, were  lacking,  with  the  exception  of  the  extraordinary 
spasmodic  movements  to  which  reference  has  been  made. 
It  appeared  that  these  movements  did  not  persist  in  deep 
sleep  but  were  present  when  she  was  sleeping  lightly.  There 
was  complaint  of  considerable  pain  about  the  neck  and  back 
of  the  head,  due  undoubtedly  to  the  constant  muscular 
contractions. 

In  spite  of  very  large  doses  of  bromide,  with  codeine  and 
a  small  amount  of  hyoscine,  which  led  to  a  certain  degree  of 
gastric  disturbance,  with  vomiting,  the  spasmodic  movements 
continued  and  increased  in  violence,  with  the  involvement  of 
more  muscles;  on  one  occasion,  for  a  period  of  three  hours, 
after  a  rather  sudden  onset,  the  movements  became  so  vio- 
lent that  the  bedclothes  could  not  be  kept  on,  and  the  suffer- 
ing from  the  violent  muscular  contractions  was  extreme. 
A  doubtful  hallucinatory  state,  presumably  due  to  the  large 
amount  of  medicine  administered,  developed,  but  in  general 


292  CASE    HISTORIES    IN    NEUROLOGY. 

the  mind  was  perfectly  clear,  and  capable,  in  a  measure, 
of  controlling  the  spasm.  When  the  patient  was  seen,  follow- 
ing this  period  of  motor  disturbance,  she  was  exhausted 
and  drowsy,  having  some  difficulty  in  speech  from  the  mus- 
cular spasm,  and  a  very  slight  and  somewhat  doubtful 
appearance  of  external  strabismus. 

She  was  transferred  to  a  hospital,  where  she  remained,  under 
close  supervision  and  careful  nursing,  for  one  week,  with 
constantly  diminishing  attacks  of  muscular  spasm.  Further 
investigation  during  her  stay  at  the  hospital  disclosed  vari- 
ous obsessional  traits,  an  example  of  which  was  a  marked  dis- 
like of  food,  associated  with  a  feeling  of  more  or  less  disgust; 
this  was  traced  to  an  experience  at  the  age  of  eleven,  when 
she  was  forced  to  eat  calves'  brain,  which  she  forthwith 
vomited.  She  also  had  a  curious  and  unexplained  dislike  to 
a  member  of  her  family,  whose  presence,  she  said,  "  made 
her  nerv^ous  ";  she  had  had  two  love  affairs,  the  first  some- 
what disastrous,  and  the  second  still  going  on;  her  home  life 
was,  in  certain  respects,  uncomfortable;  she  was  extremely 
sensitive  and  on  the  whole  uncommunicative.  She  felt  that 
the  muscular  spasm  relieved  her  nervous  tension.  At  the 
end  of  the  week,  she  left  the  hospital  practically  free  from  the 
spasmodic  movements;  on  returning  home  she  was  able  to 
control  the  spasm  by  the  exercise  of  much  determination. 
She  was,  however,  unable  to  get  over  her  obsessions,  although 
they  no  longer  dominated  her;  she  went  on  with  her  work. 
Thereafter  she  improved;  had  good  nights,  and  increased 
in  her  capacity  of  self-control.  A  very  recent  report  stated 
that  she  has  lived  a  useful  life  for  the  past  two  years,  and  is 
practically  free  from  the  affection  for  which  she  first  sought 
relief. 

Diagnosis.  This  case  may  properly  be  included  under 
the  Hysterical  affections;  the  violent  spasmodic  movements 
limited  to  certain  groups  of  muscles,  irregular  in  onset  and 
wholly  beyond  the  control  of  the  will  in  their  most  extreme 
manifestations,  point  toward  this  diagnosis.  Chorea  is  to  be 
excluded  because  of  the  peculiar  limitation  of  the  spasm, 
together  with  its  violence,  which,  except  in  rare  instances, 
does  not  occur  in  choreic  affections.     Its  resemblance  to  an. 


PSYCHONEUROSES.  293 

extensive  tic  should  be  noted,  but  here  again  the  character 
of  the  onset,  and  the  associated  conditions,  together  with  the 
rapid  improvement  under  treatment,  render  the  diagnosis 
of  Hysteria  much  more  probable  in  spite  of  the  fact  that 
other  physical  signs  of  that  neurosis  were  not  manifest. 

Prognosis.  The  patient  improved  greatly  under  the  treat- 
ment detailed  below,  and  undoubtedly,  if  proper  conditions 
can  be  secured,  will  lead  a  useful  and  active  life. 

Treatment.  The  only  effectual  treatment  in  this  case  was 
an  appeal  on  the  mental  side;  the  primary  administration 
of  bromides,  codeine  and  hyoscine  were  entirely  inefficacious, 
and,  in  fact,  during  their  administration  the  difficulty  increased 
rather  than  diminished;  when,  however,  she  was  removed 
to  quiet  surroundings,  away  from  the  family  influences, 
and  treated  by  psychotherapeutic  means,  improvement  was 
striking,  and  apparently  has  been  lasting.  The  attempt 
was  made  to  analyze  the  patient's  life  and  mental  state,  with 
the  object  of  determining  the  possible  sources  of  her  later 
neurotic  manifestations;  this  attempt  met  with  partial  suc- 
cess, as  indicated  in  the  history;  with  this  knowledge  it  was 
possible  to  explain,  in  a  measure  at  least,  the  origin  of  her 
symptoms,  to  assist  her  in  the  effort  at  self-control,  and  to 
indicate  the  direction  in  which  self-discipline  should  be  ex- 
ercised. She  was  a  person  of  much  intelligence,  and  appre- 
ciated both  the  reasonableness  of  the  explanation  and  the 
necessity  of  personal  effort.  The  result  seems  to  have  justi- 
fied the  expectation  of  relief  by  this  means. 


294  CASE    HISTORIES    IN    NEUROLOGY. 

Case  113.  C,  a  woman  of  thirty- two,  unmarried,  had  al- 
ways been  well  although  of  a  somewhat  nervous  temperament ; 
she  had,  up  to  the  time  of  her  present  difficulty,  never  had 
attacks  of  hysteroid  character.  Three  days  before  being  ex- 
amined, while  attempting  to  go  on  board  a  steamer,  the  gang 
plank  on  which  she  was  standing  slipped,  causing  her  to 
fall  with  the  plank  ten  to  fifteen  feet;  she  was  able  to  cling 
to  the  plank,  but  was  immersed  in  the  water  up  to  her  waist; 
she  was  bruised,  and  suffered,  as  she  said,  "  a  violent  nervous 
shock."  She  was  taken  home  and  was  in  a  reasonably  normal 
state  the  following  day;  the  next  day,  however,  she  was  worse, 
and,  according  to  her  family,  had  attacks  of  opisthotonos. 
When  first  examined  her  general  appearance  and  manner 
was  of  a  person  under  considerable  nervous  strain.  She  was 
slender  in  build,  languid  in  manner,  and  at  times  appeared 
as  if  in  pain.  Her  facial  expression  was  somewhat  unnatural, 
due  partly  to  a  constant  opening  and  closing  of  her  eyes. 
Her  chief  complaint  was  of  the  right  side  of  her  neck.  The 
condition  of  the  patient  was  such  that  a  complete  physical 
examination  was  not  undertaken  at  the  first  visit.  The  follow- 
ing facts  were,  however,  noted.  There  was  a  bruise  on  the 
right  elbow,  and  a  large  ecchymosis  on  the  upper  and  under 
part  of  the  left  thigh,  which  was  tender.  There  was  also  a 
sprain  of  the  right  ankle;  the  pulse  was  80  and  of  fair 
quality;  there  was  a  slight  but  definite  left  hemianesthesia. 
While  being  examined  she  had  a  typical  hysteroid  attack, 
with  opisthotonos,  lasting  about  three  minutes.  There  were 
no  convulsive  movements,  and  an  attempt  to  abate  the  attack 
by  verbal  suggestion  was  unavailing.  She  presumably 
did  not  lose  consciousness. 

At  a  second  visit,  a  few  days  later,  the  patient  was  found 
lying  with  her  eyes  closed,  in  an  apathetic,  half  somnolent 
condition,  from  which,  by  degrees,  she  was  completely  aroused, 
and  appeared  bright  and  relatively  well,  except  for  occasional 
complaint  of  pain  about  the  back  of  the  head.  The  attacks 
of  opisthotonos  had  decreased  somewhat  in  number,  but 
not  in  severity ;   her  sleep  had  been  poor. 

Physical  examination  showed  the  following  conditions: 
there  were  painful  points  on  deep  pressure  at  the  back  of  the 


PSYCHONEUROSES.  295 

head  In  the  region  of  muscular  Insertions  below  the  occipital 
protuberances,  also  at  the  inner  bolder  of  the  left  scapula; 
passive  movements  of  the  arms  were  unhindered,  except 
by  some  reference  of  pain  to  the  neck;  the  grip  of  the  right 
hand  was  diminished,  probably  on  account  of  pain;  there 
were  no  tremors ;  there  was  tendency  to  foot-drop  on  the  right, 
and  passive  movements  of  the  legs  occasioned  pain,  both  in 
the  thighs  and  legs;  the  knee  jerks  were  active  and  equal; 
plantar  response  was  normal;  no  abdominal  or  epigastric 
reflex  was  obtained.  The  heart  was  normal  and  slow  in  ac- 
tion; the  pulse  64,  of  good  quality;  the  pupils  reacted  nor- 
mally, but  by  rough  test  there  appeared  to  be  a  concentric 
narrowing  of  the  left  visual  field;  general  sensation  was  re- 
duced on  the  left  side,  particularly  In  the  leg;  the  arm  was 
not  affected,  nor  was  the  upper  part  of  the  chest  and  face, 
In  contrast  to  the  earlier  examination,  when  the  hemianes- 
thesia was  complete;  there  was  considerable  complaint  of 
vertigo,  particularly  when  raised  In  bed,  and  when  her  head 
was  suddenly  turned;  she  felt  tired  and  exhausted  after 
being  lifted.  As  time  passed,  the  attacks  of  opisthotonos 
grew  constantly  fewer;  on  the  other  hand,  she  became  more 
nervous  and  emotional  and  was  greatly  disturbed  by  the 
whistle  of  a  steamboat.  She  began  to  sit  up;  talked  some- 
what more  freely  and  with  less  effort,  but  still  complained 
of  exhaustion  and  weakness.  There  were  various  complaints 
of  pain;  a  partial  hemianesthesia  persisted,  and  there  was 
apparent  great  loss  of  strength  in  the  right  hand,  to  such  a 
degree  that  complete  flexion  of  the  fingers  seemed  Impossible ; 
thereafter  there  was  much  nervous  disturbance  of  a  general 
sort;  she  was  up  and  about,  but  the  smallest  effort  gave 
rise  to  various  symptoms,  such  as  "  a  floating  sensation," 
nausea,  globus  hystericus,  a  sense  of  suffocation;  the  former 
anesthesia  gave  place  to  a  partial  disturbance  of  sensation 
In  the  region  of  the  right  ulnar  nerve  of  the  hand;  the  nerve 
trunk  at  the  elbow  was  also  painful  on  pressure;  she  had 
"  cold  and  hot  flashes,"  attacks  of  trembling,  great  emotional- 
ism, much  pain  In  the  back  of  the  head,  shooting  over  the 
eyes;  tremor  of  the  eyelids,  and  what  she  called  "  fainting 
attacks."     An  attempt  to   elicit  the  knee  jerk   on  the  left 


296  CASE   HISTORIES    IN    NEUROLOGY. 

led  to  great  complaint  of  pain  in  and  about  the  joint,  and  much 
general  reaction. 

At  a  later  examination  the  anesthesia  of  the  right  arm,  pre- 
viously noted,  had  extended  up  to  the  shoulder;  there  was 
another  area  of  anesthesia  over  the  right  chest.  Several 
months  elapsed,  with  general  improvement,  so  that  it  was 
possible  for  her  to  attend  to  her  work  to  a  certain  extent, 
which  was  manual  in  character;  she  was  mentally  more 
stable,  but  continued  to  complain  of  pain  at  the  right  elbow, 
and  with  disturbance  of  the  left  leg.  She  had  not  ventured 
out  alone;  her  sleep  was  poor,  her  appetite  good,  the  bowels 
constipated.  These  symptoms  continued,  with  variations, 
and  new  ones  were  added.  Her  statement  at  this  time  was 
as  follows:  She  had  not  been  able  to  work  because  of  lack 
of  strength;  she  felt  sick  "all  over"  if  she  attempted  to 
work;  her  right  arm  felt  cold  and  weak;  she  felt  that  her 
"courage  was  breaking";  she  had  had  one  or  two  typical 
hysterical  attacks;  she  had  a  particular  dread  of  the  water; 
she  suffered  also  from  "  clammy  sensations,"  and  her  whole 
left  side  felt  at  times  rigid,  "as  if  starched."  Examination 
of  the  urine  showed  no  significant  abnormality.  She  had 
lost  about  ten  pounds  since  the  accident. 

The  case  was  later  adjusted  in  the  courts,  and  decided 
improvement  followed;  but  at  least  for  some  years  there 
was  not  a  complete  restoration  to  her  former  state  of  health. 

Diagnosis.  So  far  as  known,  this  patient  was  well  before 
the  relatively  trifling  accident  stated  in  the  foregoing  ac- 
count. Immediately  thereafter  symptoms  of  a  nervous 
character  developed,  many  of  them  of  an  hysterical  sort; 
the  situation  was  complicated  by  a  suit  for  damages  against 
the  steamboat  company.  The  diagnosis,  therefore,  of  Trau- 
matic Neurosis  is  entirely  justified.  It  was  evident  from  the 
first  that  there  was  no  underlying  organic  cause  for  her  vari- 
ous and  varied  disturbances.  The  diagnosis  of  such  a  neuro- 
sis is  usually  not  difficult,  coming  on  as  it  does  after  an  acci- 
dent, and  usually,  though  by  no  means  always,  associated 
with   litigation. 

Prognosis.  The  outcome  of  neurotic  disturbances  due  to 
injury    is    varied,    depending    upon    the    various    emotional 


PSYCHONEUROSES.  297 

influences  brought  to  bear  upon  the  patient.  True  simulation 
is  rare,  but  exaggeration  of  symptoms,  partly  conscious 
and  partly  unintended,  is  a  constant  accompaniment  of  this 
type  of  disturbance.  In  estimating  the  prognosis,  therefore, 
it  is  essential  to  take  into  consideration  the  temperament 
of  the  patient,  the  character  of  the  lawyers  concerned  in  the 
transaction  and  the  various  factors  entering  into  the  litiga- 
tion. Although  in  this  case  the  symptoms  were  by  no  means 
simulated,  it  is  not  to  be  questioned  that  the  pendency  of 
litigation  and  the  gain  to  be  secured  by  a  persistence  of 
symptoms  was  influential  in  keeping  alive  the  neurosis, 
although  it  was  not  its  cause.  Improvement  began  before 
the  settlement  of  the  issue,  but  progressed  very  much  more 
rapidly  after  somewhat  liberal  damages  were  finally  awarded. 
Treatment.  Treatment  is  unavailing  until  the  suits  in 
such  cases  as  this  are  settled.  The  inherent  dread  of  court 
proceedings,  the  frequent  examinations  of  physicians,  often 
antagonistic  to  the  patient's  interest,  and  the  general  useful- 
ness to  the  patient  of  exaggeration,  all  tend  to  thwart  efforts 
at  systematic  relief.  When  the  suit  is  settled,  definite  prog- 
ress may  be  made  toward  restoring  the  nervous  equilibrium 
by  the  means  employed  for  other  neuroses  due  to  a  different 
cause.  In  this  case  great  improvement,  which  had  begun 
before  the  settlement,  progressed  in  a  greater  degree  after 
it.  The  case  has  not  been  followed  to  this  time,  but  when 
last  heard  from  showed  an  improvement  which  promised 
complete  restoration  of  usefulness. 


298  CASE  HISTORIES    IN    NEUROLOGY. 

Case  114.  A  married  man  of  fifty-seven,  a  mechanic  by 
occupation,  sought  advice  for  a  peculiar  difificulty,  par- 
ticularly associated  with  writing.  The  history,  in  brief,  was 
that,  at  the  age  of  twenty,  he  was  unexpectedly  asked  to  sign 
a  certain  legal  document.  This  he  was  able  to  do,  but  he  was 
much  perturbed  and  excited  by  the  unusual  request  and  also 
greatly  embarrassed  while  he  was  writing  because  several 
men  who  were  standing  about  made  jocose  remarks  at  his 
expense.  From  that  time  on,  whenever  he  was  called  upon 
to  sign  his  name  or  write  in  the  presence  of  others,  he  became 
so  excited  and  his  hand  trembled  to  such  a  degree  that  he 
found  it  extremely  difficult  to  continue.  He  was,  however, 
able  to  write  perfectly  well  when  persons  were  not  looking 
on.  For  many  years  his  difficulty  was  practically  confined 
to  writing,  but  about  six  years  ago,  and  thirty  years  after  the 
onset  of  his  trouble,  when  called  upon  in  connection  with  his 
employment  to  do  a  piece  of  stitching,  he  noticed  the  same 
nervous  trembling  which  had  so  long  hindered  his  writing, 
and  this  also  he  has  been  wholly  unable  to  overcome  since. 
As  with  the  writing,  he  is  able  to  stitch  or  do  other  work 
properly  when  he  is  alone  and  undisturbed,  but  if  persons 
are  waiting  for  the  work  to  be  done,  or  if  it  must  be  com- 
pleted at  a  fixed  time,  he  finds  himself  incapacitated.  A 
strong  determination  to  accomplish  what  he  has  to  do  merely 
serves  to  make  the  trembling  and  nervousness  worse.  In  all 
other  respects  he  considered  himself  well,  and  he  had  every 
appearance  of  being  a  hard-working,  somewhat  stolid  and 
unemotional  man. 

Examination  showed  normal  pupils  and  knee  reflexes. 
His  pulse  was  84;  the  blood  pressure  somewhat  high;  the 
heart  normal.  An  attempt  to  write  his  name  resulted  in  an 
entirely  legible  but  tremulous  signature. 

Diagnosis.  It  is  difficult  and  unnecessary  to  give  this 
condition  a  definite  name.  The  fact  of  essential  importance 
which  the  case  illustrates  is  that  an  early  impression  appar- 
ently trifling  in  character  may  be  the  starting  point  of  a 
condition  persisting  through  life  as  a  neurosis.  In  the  case 
of  this  man,  the  attempt  to  write  his  name  at  the  age  of 
twenty,  under  circumstances  to  him  of  peculiar  embarrass- 


PSYCHONEUROSES.  299 

ment,  was  sufficient  to  perpetuate  by  association  a  nervous 
disorder  of  so  pronounced  a  character  that  he  was  wholly 
unable  to  rid  himself  of  it  through  a  long  life  of  useful  activity. 
As  often  happens  in  conditions  of  this  type,  after  a  varying 
period  of  time  allied  disorders  manifested  themselves  in  the 
form  of  tremor  and  agitation  when  he  was  called  upon  to 
perform  other  coordinated  acts  promptly  or  while  under 
observation.  This  irradiation,  as  it  were,  of  symptoms  is  an 
important  matter  to  bear  in  mind  in  the  analysis  of  such  cases. 
By  this  means  a  primarily  simple  manifestation  may  often 
develop  into  a  complexity  exceedingly  difficult  to  unravel. 

Prognosis.  Had  it  been  possible  to  treat  the  condition  on 
its  earliest  manifestation,  there  is  little  doubt  that  it  could 
have  been  entirely  relieved.  After  the  lapse  of  thirty-seven 
years  it  is  naturally  very  much  more  difficult  to  break  up  an 
association  fixed  by  so  long  a  period  of  repetition.  It  is, 
therefore,  not  to  be  expected  that  this  patient  will  ever  fully 
regain  the  necessary  confidence  in  his  capacity  to  write  with 
equanimity  under  all  circumstances  which  he  lost  at  twenty. 

Treatment.  The  patient  was  perfectly  healthy  in  body 
and  also  in  mind  except  for  the  idiosyncrasies  mentioned  in 
the  foregoing  history.  Nothing  is  gained  by  drug  treatment 
in  such  cases,  and  harm  may  often  be  done  by  impressing  the 
patient  with  the  inefficiency  of  methods  in  which  he  had  hope, 
and  in  which  the  physician  may  have  expressed  confidence. 
A  primary  appeal  to  the  reason,  through  explanation,  and 
thereby  the  removal  of  apprehension  as  to  the  imagined 
significance  of  the  incapacity,  is  the  method  to  be  employed. 
The  results  are  often  gratifying  quite  beyond  expectation. 


INDEX. 


Abasia,    senile    trepidant,    see    Senile 

trepidant  abasia. 
Abscess,  cerebral,  187,  190. 
Acromegaly,  218,  263. 
Acroparesthesia,  267. 
Alcohol,  24. 
Amyotrophic     bulbar     paralysis,     see 

Paralysis,  amyotrophic  bulbar, 
lateral  sclerosis,  see  Sclerosis,  amyo- 
trophic lateral. 
Analgesia,  17. 
Anesthesia,  17,  296. 
Anode,  15. 

Anxiety  neurosis,  290. 
Aphasia,  155,  187,  228. 
sensory,  183,  185. 
motor,  164. 
Aphonia,  228. 
Apoplectiform     attack     in     paralytic 

dementia,  159. 
Apoplexy,  163,  168. 
Argyll-Robertson  pupil,  90,  93,  95,  loi, 

160. 
Arsenic,  28. 

Arteriosclerosis,  100,  177,  226,  228. 
Association  neurosis,  299. 
Astereognosis,  155,  207. 
Ataxia,  98,  152,  244. 
Friedreich's,  152. 
Intention  type,  127. 
Ataxic     paraplegia,     see     Paraplegia, 

ataxic. 
Atrophy,      muscular,      see      Muscular 

atrophy. 
Auditory  vertigo,  270. 

Babinski  sign,  170. 

Bell's  palsy,  56. 

Brachial  neuritis,  see  Neuritis,  brachial. 

Brachial  plexus,  see  Plexus,  brachial. 

Brain,  153. 

contusion  of,  238. 

contusion  and  concussion  of,  241. 


cortex,  l7- 

disease,  focal  symptoms,  155. 

disease,  general  symptoms,  155. 

disease,  symptomatology  of,  155, 

embolism,  164,  174. 

hemorrhage,  164. 

motor  aphasia,  164. 

softening,  164,  166. 

thrombosis,  164. 

tumor,  202,  207,  211,  214,  218,  234. 

tumor,  vertigo  of,  270. 
Brown-Sequard  type  of  paralysis,  see 
Paralysis,   Brown-Sequard  type 
of. 
Bulbar  paralysis,  see  Paralysis,  bulbar. 
Bursitis,  sub-deltoid,  46. 

Capsule,  internal,  11,  63,  153,  162,  166. 

Carcinoma,  230. 

Carcinoma  of  the  vertebrae,  138. 

carcinomatous,    metastatic,    infiltra- 
tion of,  140. 
Cathode,  15. 

Faradism,  15. 

Galvanism,  15. 
Central  motor  neurones,  see  Neurones, 

central  motor. 
Cerebral  abscess,  see  Abscess,  cerebral. 

Edema,  238,  241. 

paralysis  of  children,  see  Parahsis, 
cerebral,  of  children. 

syphilis,  235. 

tumor,  234. 
Choked  disk,  148,  155,  193,  202,  235. 
Chorda    tympani    nerv^e,    see    Nerve, 

chorda  tympani. 
Chorea,  246,  248,  292. 
Conjugate  deviation,  211. 
Contact,  63. 

Coordination,  disturbance  of,  17. 
Cord,  spinal,  see  Spinal  cord. 
Cranial  nerv-es,  see  Ner\^es,  cranial. 
Cranial  nerve  involvement,  230. 


302 


INDEX. 


Degeneration,  combined,  103. 
Degeneration    of    spinal    cord,    diflfuse 

combined,  loi. 
Degeneration,  partial,  15. 
Degeneration,  reaction  of,  14. 
Dementia     paralytica,    see     Paralytic 

dementia. 
Diagnostic  methods,  11. 
Diffuse  combined  degeneration  of  the 

spinal    cord,    see    Spinal    cord, 

diffuse    combined    degeneration 

of. 
Disk,  choked,  see  Choked  disk. 
Dissociation  of  sensation,  129. 
Dorsal  columns,  64. 
Dorsal  tracts,  17. 
Dystrophy,  83. 

Edema,  cerebral,  238,  241. 
Electrical  alterations,  16,  19. 
Electrical  reactions,  13,  14. 
Embolism,  see  Brain. 
Encephalitis,  199. 
Epilepsy,  171,  256,  258. 
Jacksonian  type,  261. 
Epileptic  seizures,  162. 
Exophthalmic   goitre,   see    Goitre,  ex- 
ophthalmic. 
Eyestrain,  262. 

Facial  nerve,  see  Nerve,  facial, 
paralysis,  see  Paralysis,  facial. 

Faradic  current,  14. 

Faradism,  see  Cathode,  faradism. 

Fever,  typhoid,  see  Typhoid  fever. 

Fillet,  63. 

Filterable  virus,  see  Virus,  filterable. 

Flaccidity,  16. 

Flaccidity  with  hypotonicity,  15. 

Foot-drop,  55. 

Fracture  of  spine,  see  Spine,  fracture 
of. 

Fraenkel  coordinative  exercises,  loi. 

Friedreich's  ataxia,  see  Ataxia,  Fried- 
reich's. 

Galvanic  current,  14. 
Galvanism,  see  Cathode,  galvanism. 
Gangrene,  symmetrical,  272. 
Gliosis,  64,  130. 


Goitre,  exophthalmic,  252. 

Habit  spasm,  see  Tic. 
Hemianesthesia,  295. 
Hemianopsia,  153,  155,  181,  183,  185. 
Hemiplegia,  20,  155,  162,  170,  199. 

infantile,  171. 

sensory,  153. 
Herpes  zoster,  277. 
Hydrocephalus,  220. 
Hyperesthesia,  17. 
Hypochondriasis,  285. 
Hypophysis,  2 1 8. 
Hypotonicity,  13,  16. 

with  flaccidity,  15. 
Hysteria,  292,  293. 

Incontinence,  urinary,  108. 

Incoordination,  19. 

Inhibitory  influences,  14. 

Injury,    brachial    plexus,    see    Plexus, 

brachial,  injury  to. 
Internal  capsule,  see  Capsule,  internal. 
Intracranial  pressure,  increased,  202. 

Joint  sensibility,  see  Sensibility,  joint. 

Knee  jerk,  13,  16. 
mechanism  of,  14. 

Lancinating  pains,  see  Pains,  lancinat- 
ing. 
Landry's  paralysis,  75. 
Lead  poisoning,  30,  32. 
Little's  disease,  195. 
Lumbar  puncture,  149. 

Median  nerve,  see  Nerve,  median. 
Meniere's  disease,  270. 
Meningitis,  67,  70. 

tuberculous,  198,  233. 
Meningo-myelitis,  syphilitic,  136. 
Methods,  diagnostic,  11. 
Migraine,  ophthalmic,  260. 
Mind,  20. 

Mixed  nerves,  see  Nerves,  mixed. 
Monoplegia,  20,  155. 
Motion,    anatomical    and    physiologi- 
cal, II. 


INDEX. 


303 


Motor  point,  15. 
Motor  tract,  12. 

Multiple   neuritis,   see   Neuritis,    mul- 
tiple. 
Multiple  sclerosis,  see  Sclerosis,   mul- 
tiple. 
Muscular  atrophy,  13,  15,  16,  129. 
progressive,   16,   18,  32,  37,  78,  222, 

224. 
progressive,  neural  type,  8l. 
progressive,  spinal  type,  64,  83. 
Muscular  rigidity,  244. 
Musculospiral  nerve,  see  Nerve,  mus- 

culospiral. 
Myasthenia  gravis,  266. 
Myasthenic  reaction,  266. 
Myelitis,  64,  92. 

transverse,  loi,  108,  149. 
Myxedema,  254. 

Nerve,  chorda  tympani,  60. 

cranial  involvement,  230. 

facial,  56,  59. 

median,  51. 

musculospiral,  49. 

optic,  atrophy,  218. 

ulnar,  53. 
Nerves,  cranial,  154. 

mixed,  17. 

peripheral,  etiology  of,  61. 

peripheral,  general  symptomatology, 

23- 
Neuralgia,  260. 

trigeminal,  275. 
Neuritis,  24,  34,  35,  91. 

brachial,  37,  46. 

degenerative  type,  37. 

multiple,  28,  29,  130. 

peripheral,  14,  19,  28,  78. 
Neurone,  central,  16. 

central  motor,  16. 

corticospinal  motor,  12. 

peripheral,  16. 

peripheral  motor,  13,  14. 

peripheral  sensory,  17. 

spinal-peripheral,  12. 
Neuroses,  occupation,  280. 
Neurosis,  anxiety,  290. 

association,  299. 

traumatic,  296. 
Nystagmus,  127. 


Oblongata,  12,  17,  63,  228. 
Obstetrical    paralysis,    see    Paralysis, 

obstetrical. 
Occupation  neuroses,  280. 
Ophthalmic    migraine,    see    Migraine, 

ophthalmic. 
Ophthalmoplegia,  19,  221. 
Optic  nerve  atrophy,  218. 

Pain,  17,  63. 

Pains,  lancinating,  26,  90,  93,  95,  loi. 

Palsy,  see  Bell's  palsy. 

Paralysis,  13,  15,  16,  155. 

agitans,  244,  254. 

atrophic,  16,  19,  76. 

Brown-Sequard  type,  II9. 

bulbar,  19,  226. 

bulbar,  acute,  228. 

bulbar,  amyotrophic,  223. 

bulbar,  progressive,  223. 

cerebral,  of  children,  195. 

crossed,  21. 

facial,  60. 

flaccid,  13. 

flaccid,  atrophic,  15. 

individual  nerve,  22. 

Landry's,  75. 

obstetrical,  45. 

segmental,  21. 

spastic,  16,  19. 

tabo,  98. 
Paralytica  dementia,  98,  156,  159. 

apoplectiform  attack  in,  159. 
Paraphasia,  183,  185. 
Paraplegia,  21. 

ataxic,  19,  64,  loi,  103,  144. 

spastic,  16,  127. 
Paresis,  13. 
Paresthesia,  17. 
Parkinson's      disease,      see      Paralysis 

agitans. 
Peripheral  nerves,  see  Nerves,  periph- 
eral. 
Peripheral  neuritis,  see  Neuritis,  periph- 
eral. 
Peripheral  sensory-  neurones,  see  Neu- 
rone, peripheral  sensory. 
Pes  pedunculi,  12,  63. 
Plexus,  brachial,  35. 

brachial,  injury  to,  44. 
Polioencephalomyelitis,  70,  75. 


304 


INDEX. 


Poliomyelitis,  64,  70,  73,  75,  108,  199. 

anterior,  18,  65. 

ascending  type,  75. 

meningeal,  68. 

peripheral  type,  68. 
Pons,  12,  63,  211. 
Pontine  lesions;  211. 
Pott's  disease,  see  Tuberculosis. 
Pre-Rolandic  cortex,  63. 
Progressive  bulbar  paralysis,  see   Pa- 
ralysis, bulbar,  progressive. 
Progressive     muscular     atrophy,     sec 

Muscular  atrophy,  progressive. 
Propulsion,  244. 
Psychasthenia,  93. 
Psychoneuroses,  283. 
Psychotherapeutics,  293. 
Pyramidal  tract,  12,  14,  16,  63,  64. 

Ra^'naud's  disease,  272. 
Reaction  of  degeneration,  see   Degen- 
eration, reaction  of. 
Reactions,  electrical,  13,  14. 
Reflex  arc,  14,  16. 

Reflexes,  tendon,  see  Tendon  reflexes. 
Rheumatism,  89. 

Sacro-iliac  articulation,  42. 

Salvarsan,  89. 

Sarcomatous  sciatica,  39. 

Scanning  speech,  127. 

Sciatica,  38,  39,  41,  42. 
sarcomatous,  39. 

Sclerosis,  amyotrophic  lateral,   l6,   19, 
64,  86,  loi. 
arterio,  see  Arteriosclerosis, 
multiple,  64,  123,  127,  244. 

Segmental     paralysis,     see     Paralysis, 
segmental. 

Senile  trepidant  abasia,  179. 

Sensation,  anatomical  and  physiologi- 
cal, 17. 

Sensibility,  joint,  17,  63. 

Sensory  fibers,  17. 

Sensory    hemiplegia,    see    Hemiplegia, 
sensory. 

Sensory  tracts,  63. 

Simulation,  297. 

Sinus  thrombosis,  193. 

Spasm,  tic  or  habit,  see  Tic. 


Spasmodic  torticollis,  see  Torticollis, 
spasmodic. 

Spastic  paraplegia,  see  Paraplegia, 
spastic. 

Spasticity,  16. 

Spina  bifida,  133. 

Spinal  progressive  muscular  atrophy, 
see  Muscular  atrophy,  progres- 
sive spinal. 

Spinal  cord,  12,  63,  121. 

diffuse    combined    degeneration    of, 

lOI. 

hemorrhage  of,  121. 

injury  to,  1 12,  113. 

metastatic     carcinomatous     infiltra- 
tion of,  140. 

systemic  lesion  of,  127. 

transverse  lesion  of,  105,  115. 

tumor  of,  104,  149. 
Spine,  fracture  of,  109. 

tuberculosis  of,  138. 
Sub-deltoid  bursitis,  see  Bursitis,  sub- 
deltoid. 
Symmetrical  gangrene,  272. 
Syphilis,  90. 

cerebral,  235. 
Syphilitic  meningo-myelitis,  136. 
Syringomyelia,  35,  64,  78,  129,  130. 

Tabes,  25,  26,  64,  88,  92,  95,  98,  loi. 

peripheral  pseudo,  26. 

superior  type  of,  95. 
Tabo-paralysis,  see  Paralysis,  tabo. 
Taste,  60. 

Temperature,  17,  63. 
Tendon  reflexes,  13. 
Thalami,  63. 

Tic  or  habit  spasm,  246,  248,  293. 
Tinnitus,  270. 

Torticollis,  spasmodic,  250. 
Tract,  motor,  see  Motor  tract. 
Tract,  pyramidal,  see  Pyramidal  tract. 
Tracts,  dorsal,  see  Dorsal  tracts. 
Tracts,  sensory,  see  Sensory  tracts. 
Transverse      myelitis,      see      Myelitis, 

transverse. 
Trauma,  64. 

Traumatic  neurosis,  296. 
Tremor,  127. 

Trigeminal  neuralgia,  275. 
Trophic  functions,  18. 


INDEX. 


305 


Tuberculosis,  64,  104,  138,  207. 

of  the  spine,  138. 
Tumor,  cerebral,  see  Brain,  tumor. 

extradural,  143. 

of  the  spinal  cord,  see  Spinal  cord, 
tumor  of. 
Typhoid  fever,  53,  70. 

Ulnar  nerve,  see  Nerve,  ulnar. 


Urotropin,  76. 

Ventral  horns,  12,  13,  64. 
Vertigo,  auditory,  270. 
of  brain  tumor,  270. 
Virus,  filterable,  76. 
Visual  fields,  20I. 

Wassermann  reaction,  34. 
serum  test,  91. 


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Case  histories  in  neurology 

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